Method for ablating body tissue

ABSTRACT

A tissue ablation system for treating fibrillation in a patient comprises a steerable interventional catheter having an energy source that emits a beam of energy to ablate tissue thereby creating a conduction block for aberrant electrical pathways. The system also includes a handle disposed near a proximal end of the interventional catheter and has an actuation mechanism for steering the interventional catheter. A console allows the system to be controlled and provides power to the system, and a display pod is electrically coupled with the console. The display pod has a display panel to display system information to a user and allows the user to control the system. A catheter pod is releasably coupled with the handle electrically and mechanically, and also electrically coupled with the display pod.

CROSS-REFERENCES TO RELATED APPLICATIONS

The present application is a continuation of U.S. patent applicationSer. No. 11/747,862 now U.S. Pat. No. 7,950,397 filed May 11, 2007,which is a non-provisional of, and claims the benefit of U.S.Provisional Patent Application Nos. 60/747,137 filed May 12, 2006, and60/919,831 filed Mar. 23, 2007; the entire contents of which areincorporated herein by reference.

All publications and patent applications mentioned in this specificationare herein incorporated by reference to the same extent as if eachindividual publication or patent application was specifically andindividually indicated to be incorporated by reference.

BACKGROUND OF THE INVENTION

1. Field of the Invention

In this invention we describe a device and a method for creatingablation zones in human tissue. More specifically, this inventionpertains to the treatment of atrial fibrillation of the heart by usingultrasound energy.

2. Background

The condition of atrial fibrillation is characterized by the abnormal(usually very rapid) beating of left atrium of the heart which is out ofsynch with the normal synchronous movement (“normal sinus rhythm”) ofthe heart muscle. In normal sinus rhythm, the electrical impulsesoriginate in the sino-atrial node (“SA node”) which resides in the rightatrium. The abnormal beating of the atrial heart muscle is known asfibrillation and is caused by electrical impulses originating instead inthe pulmonary veins (“PV”) [Haissaguerre, M. et al., SpontaneousInitiation of Atrial Fibrillation by Ectopic Beats Originating in thePulmonary Veins, New England J. Med., Vol. 339:659-666].

There are pharmacological treatments for this condition with varyingdegree of success. In addition, there are surgical interventions aimedat removing the aberrant electrical pathways from PV to the left atrium(“LA”) such as the Cox-Maze III Procedure [J. L. Cox et al., Thedevelopment of the Maze procedure for the treatment of atrialfibrillation, Seminars in Thoracic & Cardiovascular Surgery, 2000; 12:2-14; J. L. Cox et al., Electrophysiologic basis, surgical development,and clinical results of the maze procedure for atrial flutter and atrialfibrillation, Advances in Cardiac Surgery, 1995; 6: 1-67; and J. L. Coxet al., Modification of the maze procedure for atrial flutter and atrialfibrillation. II, Surgical technique of the maze III procedure, Journalof Thoracic & Cardiovascular Surgery, 1995; 2110:485-95]. This procedureis shown to be 99% effective [J. L. Cox, N. Ad, T. Palazzo, et al.Current status of the Maze procedure for the treatment of atrialfibrillation, Seminars in Thoracic & Cardiovascular Surgery, 2000; 12:15-19] but requires special surgical skills and is time consuming.

There has been considerable effort to copy the Cox-Maze procedure for aless invasive percutaneous catheter-based approach. Less invasivetreatments have been developed which involve use of some form of energyto ablate (or kill) the tissue surrounding the aberrant focal pointwhere the abnormal signals originate in PV. The most common methodologyis the use of radio-frequency (“RF”) electrical energy to heat themuscle tissue and thereby ablate it. The aberrant electrical impulsesare then prevented from traveling from PV to the atrium (achievingconduction block within the heart tissue) and thus avoiding thefibrillation of the atrial muscle. Other energy sources, such asmicrowave, laser, and ultrasound have been utilized to achieve theconduction block. In addition, techniques such as cryoablation,administration of ethanol, and the like have also been used.

There has been considerable effort in developing the catheter basedsystems for the treatment of AF using radiofrequency (RF) energy. Onesuch method is described in U.S. Pat. No. 6,064,902 to Haissaguerre etal. In this approach, a catheter is made of distal and proximalelectrodes at the tip. The catheter can be bent in a J shape andpositioned inside a pulmonary vein. The tissue of the inner wall of thePV is ablated in an attempt to kill the source of the aberrant heartactivity. Other RF based catheters are described in U.S. Pat. No.6,814,733 to Schwartz et al., U.S. Pat. No. 6,996,908 to Maguire et al.,U.S. Pat. No. 6,955,173 to Lesh; and U.S. Pat. No. 6,949,097 to Stewartet al.

A source used in ablation is microwave energy. One such device isdescribed by Dr. Mark Levinson [(Endocardial Microwave Ablation: A NewSurgical Approach for Atrial Fibrillation; The Heart Surgery Forum,2006] and Maessen et al. [Beating heart surgical treatment of atrialfibrillation with microwave ablation. Ann Thorac Surg 74: 1160-8, 2002].This intraoperative device consists of a probe with a malleable antennawhich has the ability to ablate the atrial tissue. Other microwave basedcatheters are described in U.S. Pat. No. 4,641,649 to Walinsky; U.S.Pat. No. 5,246,438 to Langberg; U.S. Pat. No. 5,405,346 to Grundy, etal.; and U.S. Pat. No. 5,314,466 to Stern, et al.

Another catheter based method utilizes the cryogenic technique where thetissue of the atrium is frozen below a temperature of −60 degrees C.This results in killing of the tissue in the vicinity of the PV therebyeliminating the pathway for the aberrant signals causing the AF [A. M.Gillinov, E. H. Blackstone and P. M. McCarthy, Atrial fibrillation:current surgical options and their assessment, Annals of ThoracicSurgery 2002; 74:2210-7]. Cryo-based techniques have been a part of thepartial Maze procedures [Sueda T., Nagata H., Orihashi K., et al.,Efficacy of a simple left atrial procedure for chronic atrialfibrillation in mitral valve operations, Ann Thorac Surg 1997;63:1070-1075; and Sueda T., Nagata H., Shikata H., et al.; Simple leftatrial procedure for chronic atrial fibrillation associated with mitralvalve disease, Ann Thorac Surg 1996; 62:1796-[800]. More recently, Dr.Cox and his group [Nathan H., Eliakim M., The junction between the leftatrium and the pulmonary veins, An anatomic study of human hearts,Circulation 1966; 34:412-422, and Cox J. L., Schuessler R. B., BoineauJ. P., The development of the Maze procedure for the treatment of atrialfibrillation, Semin Thorac Cardiovasc Surg 2000; 12:2-14] have usedcryoprobes (cryo-Maze) to duplicate the essentials of the Cox-Maze IIIprocedure. Other cryo-based devices are described in U.S. Pat. Nos.6,929,639 and 6,666,858 to Lafontaine and U.S. Pat. No. 6,161,543 to Coxet al.

More recent approaches for the AF treatment involve the use ofultrasound energy. The target tissue of the region surrounding thepulmonary vein is heated with ultrasound energy emitted by one or moreultrasound transducers. One such approach is described by Lesh et al. inU.S. Pat. No. 6,502,576. Here the catheter distal tip portion isequipped with a balloon which contains an ultrasound element. Theballoon serves as an anchoring means to secure the tip of the catheterin the pulmonary vein. The balloon portion of the catheter is positionedin the selected pulmonary vein and the balloon is inflated with a fluidwhich is transparent to ultrasound energy. The transducer emits theultrasound energy which travels to the target tissue in or near thepulmonary vein and ablates it. The intended therapy is to destroy theelectrical conduction path around a pulmonary vein and thereby restorethe normal sinus rhythm. The therapy involves the creation of amultiplicity of lesions around individual pulmonary veins as required.The inventors describe various configurations for the energy emitter andthe anchoring mechanisms.

Yet another catheter device using ultrasound energy is described byGentry et al. [Integrated Catheter for 3-D Intracardiac Echocardiographyand Ultrasound Ablation, IEEE Transactions on Ultrasonics,Ferroelectrics, and Frequency Control, Vol. 51, No. 7, pp 799-807]. Herethe catheter tip is made of an array of ultrasound elements in a gridpattern for the purpose of creating a three dimensional image of thetarget tissue. An ablating ultrasound transducer is provided which is inthe shape of a ring which encircles the imaging grid. The ablatingtransducer emits a ring of ultrasound energy at 10 MHz frequency. In aseparate publication [Medical Device Link, Medical Device and DiagnosticIndustry, February 2006], in the description of the device, the authorsassert that the pulmonary veins can be imaged and “a doctor would beable to electrically isolate the pulmonary veins by putting a linearlesion around them” (emphasis by inventors). It is unclear from thisstatement whether the ablation ring is placed around one single targetvein, or around a plurality of veins. In the described configuration ofthe catheter tip, it can be easily seen that the described ringultrasound energy source can only emit the ultrasound beam of a size toablate only one pulmonary vein at a time.

Other devices based on ultrasound energy to create circumferentiallesions are described in U.S. Pat. Nos. 6,997,925; 6,966,908; 6,964,660;6,954,977; 6,953,460; 6,652,515; 6,547,788; and 6,514,249 to Maguire etal.; U.S. Pat. Nos. 6,955,173; 6,052,576; 6,305,378; 6,164,283; and6,012,457 to Lesh; U.S. Pat. Nos. 6,872,205; 6,416,511; 6,254,599;6,245,064; and 6,024,740; to Lesh et al.; U.S. Pat. Nos. 6,383,151;6,117,101; and WO 99/02096 to Diederich et al.; U.S. Pat. No. 6,635,054to Fjield et al.; U.S. Pat. No. 6,780,183 to Jimenez et al.; U.S. Pat.No. 6,605,084 to Acker et al.; U.S. Pat. No. 5,295,484 to Marcus et al.;and WO 2005/117734 to Wong et al.

In all above approaches, the inventions involve the ablation of tissueinside a pulmonary vein or at the location of the ostium. The anchoringmechanisms engage the inside lumen of the target pulmonary vein. In allthese approaches, the anchor is placed inside one vein, and the ablationis done one vein at a time.

BRIEF SUMMARY OF THE INVENTION

One aspect of the invention provides a cardiac ablation system includingan ablation catheter having an anchor adapted to support the ablationcatheter within an atrium of a heart and an ultrasound emitter disposedradially outward from a rotation axis and from the anchor, and a controlmechanism adapted to rotate the ultrasound emitter about the rotationaxis and to provide ablation energy to the ultrasound emitter to ablateheart tissue. Some embodiments also include an ultrasound emittersupport extending radially outward from the rotation axis and supportingthe ultrasound emitter, which may be the a distal portion of theablation catheter or may be a separate element.

In some embodiments, the emitter is disposed to emit ultrasound energythrough a distal end of the support, and in other embodiments theemitter is disposed to emit ultrasound energy radially outward from aside of the support. In some embodiments, the emitter is disposed at anangle greater than zero with respect to the outer surface of thesupport.

In some embodiments, the emitter includes an ultrasound transducer andan ultrasound reflective surface disposed to reflect ultrasound energyfrom the transducer. The transducer may be disposed to direct ultrasoundenergy proximally toward the reflective surface.

In some embodiments, the control mechanism is adapted to bend theemitter support at a desired angle from the rotation axis. This anglemay be formed at a first location along the emitter support, with thecontrol mechanism being further adapted to bend the emitter support at asecond location along the emitter support.

In some embodiments, the ultrasound emitter support includes or servesas an electrode in electrical communication with the control mechanismand the anchor includes or serves as an electrode in electricalcommunication with the control mechanism.

The control mechanism may be adapted to move the anchor within a leftatrium. The anchor may extend substantially along the rotation axis,with the ablation catheter being adapted to rotate with respect to theanchor. Alternatively, the anchor may extend along an axis other thanthe rotation axis. In embodiments in which the system further includes adelivery sheath adapted to contain the ablation catheter, either thedelivery sheath or the ablation catheter may have a port through whichthe anchor extends. Some embodiments also include a second anchorsupporting the ablation catheter.

In some embodiments, the emitter is distally and proximally translatablewith respect to the anchor. In some embodiments, the emitter issupported by a transducer support extending radially outward from therotation axis and is distally and proximally translatable with respectto the anchor.

The anchor may be adapted to contact a heart tissue surface, such as theinterior wall of the atrium or an interior surface of a pulmonary vein.Some embodiments have a delivery sheath surrounding the ablationcatheter, and the anchor is expandable to contact a support cathetersurrounding the ablation catheter.

In embodiments in which the ultrasound emitter includes an ultrasoundtransducer, the system may also include a fluid source and a fluid flowpath adjacent to the transducer. The system may also have a fluid exitport adjacent to the transducer and extending from the fluid flow pathto the exterior of the ablation catheter. In embodiments in which theultrasound emitter is disposed proximal to a distal end of the ablationcatheter, the ablation catheter may also have a fluid chamber incommunication with the fluid source, disposed between the ultrasoundemitter and the distal end of the catheter, and in fluid communicationwith the distal end of the catheter. The fluid chamber may have aplurality of fluid exit channels formed in the distal end of thecatheter.

Some embodiments also have a distance sensor adapted to sense distancebetween the ultrasound emitter and a tissue surface. The ultrasoundemitter and the distance sensor may both be an ultrasound transducer.Some embodiments may also have an ablation depth sensor. The ultrasoundemitter and ablation depth sensor may both be an ultrasound transducer.

Another aspect of the invention provides a cardiac ablation systemincluding an ablation catheter having an ultrasound emitter and anultrasound emitter support extending radially outward from a rotationaxis and supporting the ultrasound emitter, and a control mechanismadapted to rotate the ultrasound emitter about the rotation axis and toprovide ablation energy to the ultrasound emitter to ablate heart tissueand adapted to bend the emitter support at a desired angle from rotationaxis. In some embodiments, the desired angle is formed at a firstlocation along the emitter support, the control mechanism being furtheradapted to bend the emitter support at a second location along theemitter support.

In some embodiments, the ultrasound emitter includes an ultrasoundtransducer, with the system further comprising a fluid source and afluid flow path adjacent to the transducer. The system may also includea fluid exit port adjacent to the transducer and extending from thefluid flow path to the exterior of the ablation catheter.

Some embodiments also have a distance sensor adapted to sense distancebetween the ultrasound emitter and a tissue surface. The ultrasoundemitter and the distance sensor may both be an ultrasound transducer.Some embodiments may also have an ablation depth sensor. The ultrasoundemitter and ablation depth sensor may both be an ultrasound transducer.

Yet another aspect of the invention provides a cardiac ablation methodincluding the following steps: inserting a treatment catheter into anatrium of a heart, the treatment catheter including an ultrasoundemitter; positioning the ultrasound emitter to face heart tissue withinthe left atrium outside of a pulmonary vein; emitting ultrasound energyfrom the ultrasound emitter while rotating the ultrasound emitter abouta rotation axis; and ablating heart tissue with the ultrasound energy toform a lesion outside of a pulmonary vein. In some embodiments, thepositioning step includes the step of bending an ultrasound emittersupport. In some embodiments, the positioning step includes the step ofmoving the ultrasound emitter parallel to the rotation axis. In someembodiments, the positioning step includes the step of anchoring thetreatment catheter, such as against the heart wall or by placing ananchor against an atrial wall outside of a pulmonary vein or within apulmonary vein. The anchoring step may also involve placing a pluralityof anchors within a plurality of pulmonary veins and/or expanding ananchor within a support catheter.

In some embodiments, the rotating step includes the step of rotating thetreatment catheter about the anchor. The rotation may include the stepof rotating the ultrasound emitter less than 360° around the rotationaxis or rotating the ultrasound emitter at least 360° around therotation axis.

In some embodiments, the ablating step includes the step of forming alesion encircling at least two pulmonary vein ostia. The method may alsoinclude forming a second lesion around two other pulmonary vein ostia,possibly forming a third lesion extending from the first lesion to thesecond lesion, and possibly forming a fourth lesion extending from thefirst, second or third lesion substantially to a mitral valve annulus.

In some embodiments, the emitting step includes the step of transmittingultrasound energy distally from a distal end of the treatment catheterand/or radially from the treatment catheter. In some embodiments, theemitting step includes the step of transmitting ultrasound energy froman ultrasound transducer (possibly in a proximal direction) andreflecting the ultrasound energy from a reflector. These embodiments mayalso include the step of rotating the reflector.

Some embodiments include the step of passing fluid through the ablationcatheter and through an exit port adjacent the ultrasound emitter. Thefluid may pass into a fluid chamber disposed between the ultrasoundemitter and the heart tissue.

Some embodiments include the step of sensing distance between theultrasound emitter and a tissue surface, such as by using the ultrasoundemitter to sense distance between the emitter and the tissue surface.The distance sensing step may include the step of sensing distancebetween the ultrasound emitter and the tissue surface over an intendedablation path prior to the ablating step and may include the step ofrepositioning the ultrasound emitter as a result of sensed distancedetermined in the sensing step.

Some embodiments include the step of sensing depth of ablation in theheart tissue, such as by using the ultrasound emitter to sense depth ofablation in the heart tissue. The speed of rotation of the ultrasoundemitter and/or the power delivered to the ultrasound emitter may bebased on sensed depth of ablation.

Some embodiments include the step of sensing thickness of the hearttissue. The speed of rotation of the ultrasound emitter and/or the powerdelivered to the ultrasound emitter may be based on sensed tissuethickness. In some embodiments, the ablating step includes the step offorming a substantially elliptical lesion segment in the heart tissue.

Still another aspect of the invention provides a cardiac ablation methodincluding the following steps: inserting a treatment apparatus into anatrium of a heart, the treatment apparatus having an ultrasound emitterand an ultrasound emitter support; positioning the ultrasound emitter toface heart tissue within the left atrium outside of a pulmonary vein;emitting ultrasound energy from the ultrasound emitter while changing abend angle in the ultrasound emitter support; and ablating heart tissuewith the ultrasound energy to form a lesion outside of a pulmonary vein.In some embodiments, the positioning step includes the step of bendingan ultrasound emitter support. In some embodiments, the positioning stepincludes the step of anchoring the treatment catheter.

Some embodiments add the step of rotating the ultrasound emitter about arotation axis during the emitting step. In some embodiments, theablating step includes the step of forming a substantially linear lesionand/or a substantially elliptical lesion segment in the heart tissue.

BRIEF DESCRIPTION OF THE DRAWINGS

The novel features of the invention are set forth with particularity inthe claims that follow. A better understanding of the features andadvantages of the present invention will be obtained by reference to thefollowing detailed description that sets forth illustrative embodiments,in which the principles of the invention are utilized, and theaccompanying drawings of which:

FIG. 1 shows the device including a catheter in one embodiment of theinvention.

FIG. 2 shows the construction of the shaft of the catheter in oneembodiment of the invention.

FIGS. 3A-C show bending of a distal portion of the catheter of FIG. 1.

FIG. 3D shows bending of the distal end of the catheter of FIG. 1 and ananchor mechanism.

FIG. 4 shows the distal tip assembly of the catheter of FIG. 1.

FIG. 5 is a view of the device in a second embodiment.

FIG. 6 shows the distal tip assembly of the catheter of FIG. 5.

FIG. 7 is a view of the device in a third embodiment.

FIG. 8 shows the distal tip assembly of the catheter of FIG. 7.

FIG. 9 is a view of the device in a fourth embodiment.

FIG. 10 shows the distal tip assembly of the catheter of FIG. 9.

FIG. 11 shows an ablation zone encircling four pulmonary veins and thedevice in one embodiment of the invention.

FIG. 12 shows two ablation zones each around two pulmonary veins.

FIG. 13 shows an ablation zone around three pulmonary veins.

FIGS. 14 to 17 show various mechanisms for the anchoring a portion ofthe catheter.

FIG. 18 shows yet another embodiment of the invention as positioned inthe left atrium of the heart.

FIG. 19 shows the use of the device of FIG. 18 in the atrium of theheart.

FIG. 20 shows the distal end of the device of FIG. 18 beyond the guidingsheath.

FIG. 21A shows the details of the transducer housing at the distal tipof the catheter.

FIG. 21B shows the transducer mounting header with fluid flow channels.

FIG. 21C shows an alternative design for the fluid pocket containmentcomponent.

FIG. 22 is a view of the construction of the therapy catheter.

FIG. 23 shows a view of the construction of the outer catheter.

FIG. 24 is a view of the characteristics of the ultrasound beam as itexits from the transducer.

FIG. 25 shows formation of the shape of an ablation lesion.

FIGS. 26 A-D show the development of the ablation lesion as function oftime.

FIGS. 27 A-D show the interaction of the ultrasound beam with the tissueat various distances from the ultrasound transducer.

FIGS. 28 A-B are views of the interaction of the ultrasound beam withthe tissue when the tissue is presented to the beam at an angle.

FIG. 29 shows the effect of the movement of heart muscle duringablation.

FIG. 30 shows the transmission and reflections of ultrasound beam fromthe target tissue.

FIG. 31 shows position of the catheter set in the left atrium in acondition when it may not be desirable to create an ablation zone.

FIG. 32 shows a catheter set designed to address the right pulmonaryveins.

FIG. 33 shows a lesion set according to one embodiment of thisinvention.

FIG. 34 shows the creation of an ablation zone near the left pulmonaryveins.

FIGS. 35A-C show the formation of a line lesion from the left pulmonaryveins to the right pulmonary veins.

FIG. 36 shows a vertical line of ablation ending at the mitral valveannulus.

FIG. 37 shows the use of the device of FIG. 31 in creating the ablationzone in the right pulmonary veins.

FIGS. 38A-J show a variety of candidate lesion sets in the left atrium.

DETAILED DESCRIPTION OF THE INVENTION

The invention described herein includes a device and methods forcreating ablation zones in tissue. The device of the invention includesan elongated member (e.g., a catheter) and an anchor mechanism. Theelongate member includes a distal tip assembly for directing energy to atissue. Uses of the invention include but are not limited to providing aconduction block for treatment of atrial fibrillation in a subject, forexample, in a patient.

One aspect of a first embodiment of the invention is shown in FIG. 1. Asshown, the device 100 includes an elongate member that can be a catheter110. In other implementations, the elongate member is a cannula, tube orother elongate structure having one or more lumens. The catheter 110 canbe made of a flexible multi-lumen tube. As shown, the catheter 110 caninclude a distal tip assembly 112 positioned at a distal portion of thecatheter 110. The tip assembly 112 can house an energy deliverystructure, for example, an ultrasound transducer subassembly 114(described in more detail in reference to FIG. 4).

Although the ablation device described herein includes a distal tipassembly having an ultrasound transducer as a source of ablation energy,it is envisioned than any of a number of energy sources can be used withvarious implementations of the invention. Suitable sources of ablationenergy include but are not limited to, radio frequency (RF) energy,microwaves, photonic energy, and thermal energy. It is envisioned thatablation could alternatively be achieved using cooled fluids (e.g.,cryogenic fluid). Additionally, although use of a single ultrasoundtransducer is described herein as an exemplary energy deliverystructure, it is envisioned that a plurality of energy deliverystructures, including the alternative energy delivery structuresdescribed herein, can be included in the distal portion of the elongatemember. In one implementation the elongate member is a catheter whereinthe distal portion of the catheter includes multiple energy deliverystructures, for example, multiple ultrasound transducers. Such acatheter distal portion can be deployable as a loop or other shape orarrangement to provide positioning of one or more of the energy deliverystructures for a desired energy delivery.

The elongate member of the device can include a bending mechanism forbending a distal portion of the elongate member (e.g., a catheter) atvarious locations (an example of such bending is shown in FIGS. 3A-D).The bending mechanism can include but is not limited to lengths ofwires, ribbons, cables, lines, fibers, filament or any other tensionalmember. In one implementation the bending mechanism includes one or morepull wires, for example, a distal pull wire and a proximal pull wire. Avariety of attachment elements for connecting the bending mechanism andthe elongate member are envisioned. As shown in FIG. 1, in oneimplementation where the elongate member is a catheter 110, the distalpull wire 116 and the transducer subassembly 114 are secured to the tipassembly 112 by means of a distal adhesive band 118. Other means ofattaching the distal pull wire 116 to a portion of the tip assembly 112include but are not limited to attachment using: adhesive, welding, pinsand/or screws or the likes. Pull wire 116 can be contained in a lumen(not shown) of the catheter 110 and can terminate at a slider 120 in aproximal housing 122. The proximal housing 122 can include variousactuating mechanisms to effect various features of the catheter, asdescribed below. In one implementation, the slider 120 can move in aslot 124 which pulls or pushes the wire 116. Since the distal end of thewire 116 is secured to the tip 112, the result is that the catheter tip112 can be bent and unbent as desired at a distal bend location 126 bymoving the slider 120. Distal bend location 126 can be positioned on thedistal tip assembly 112 as needed to achieve the desired bending of thecatheter 110.

A second analogous bending mechanism can be provided in the catheterwhich is more proximally positioned with respect to the distal tipassembly. As shown in FIG. 1, a proximal pull wire 128 can reside in alumen (not shown) of the catheter 110 and the wire 128 distal end can besecured in the catheter 110 by a proximal adhesive band 130. Thisproximal pull wire 128 can terminate in a second slider 132 at theproximal housing 122. The slider 132 can move in a second slot 134 whichallows the distal tip assembly 112 to be bent at a proximal bendlocation 136.

The elongate member can further include an anchor mechanism by which thedistal portion of the elongate member can be held in a relativelypredictable position relative to a tissue, for example, inside a chambersuch as the left atrium of the heart. As shown in FIG. 1, in oneimplementation an anchor mechanism 140 includes a pre-shaped wire loop138. In a specific implementation, the wire loop 138 is made of ashapeable wire, for example, made from a shape-memory material such asNitinol (nickel-titanium alloy). Alternatively, the anchor mechanism caninclude a loop made from any of a number of materials such as metal,plastic and/or fiber or combinations thereof. Although a loop isdescribed, it is envisioned that any of a number of shapes, curvedand/or angular, two-dimensional and/or three-dimensional can provide theanchoring required. The anchor 140 can reside in a lumen (not shown) ofthe catheter 110, and can exit from the catheter 110 through a notch 142near the distal end of the catheter 110 (see FIG. 1). The proximal endof the anchor mechanism 140 can terminate in a third slider 148 at theproximal housing 122. The third slider 148 can move in a third slot 150at the proximal housing 122, thereby producing a corresponding anchormechanism movement 144 of the anchor mechanism 140.

In one implementation, when the slider 148 is in a proximal position,the wire loop 138 can be maintained in a substantially linear shapeinside the lumen of the catheter 110 (not shown). In use, as thirdslider 148 is advanced distally in the slot 150, a distal tip of thewire loop 138 exits the notch 142 (not shown). As the slider 148 isfurther advanced, the wire loop 138 can take on the shape of apre-formed loop as it is unrestricted by the confines of a lumen (seeFIG. 3D). As shown in FIG. 1, the wire loop 138 of the anchor 140 can beadvanced further until it makes a firm contact with the tissue such asthe ceiling wall 146 of the left atrium of the heart. One function ofthe wire loop 138 is to provide a firm contact and/or stabilizationbetween the anchor mechanism 140 and the tissue, and thereby between aregion of the catheter 110 and the tissue (see FIG. 1). An additionalfunction of the anchor mechanism is to provide an axis around which allor a portion of the catheter shaft can be rotated. Such rotation of thecatheter is illustrated in FIG. 1, as arrow 152. As shown in FIG. 1, inone implementation a rotation mechanism 154, for example, a wheel, isprovided at the proximal housing 122 by which all or a portion of thecatheter 110 shaft can be rotated around the axis defined by the anchormechanism 140. As can be easily envisioned, through rotational movementabout such an axis, the most distal portion of the tip assembly 112 canbe swept in a desired path in relation to target tissue. In oneimplementation, the path of the tip assembly 212 can be a substantiallycircular path 262 inside a tissue chamber such as the left atrium of theheart (see FIG. 11).

A transducer subassembly can be secured in the distal tip assembly ofthe catheter. As shown in FIG. 1, in one implementation a transducersubassembly 114 is secured by the distal adhesive band 118. Thetransducer subassembly is described in more detail herein for variousembodiments of the invention. In one implementation, the transducersubassembly 114 includes a temperature measuring device such as athermistor or a thermocouple (not shown). The transducer can beenergized by the wires which, along with the temperature sensor wires,can be contained in a lumen of the catheter (not shown). As shown inFIG. 1, such wires can terminate in a connector, for example, atransducer connector 156 at the proximal housing 122. The connector 156can be attached to and detached from a power generator and/or controller(not shown). It is envisioned that such a power generator and/orcontroller can energize the transducer, display temperature readings andperform any of a number of functions relating to such transducers aswell understood in the art. For example, monitoring A-mode signal andthe like (e.g., B-mode). In use, as the transducer is energized, it canemit an ultrasound beam 158 towards the tissue 146. As the energy istransferred from the ultrasound beam into the tissue, the targetedtissue portion can be heated sufficiently to achieve ablation. Thus, asshown in FIG. 1, an ablation zone 160 can be created in the tissue.

During the energizing of the transducer, the transducer may becomeheated. It is envisioned that the transducer can be maintained within asafe operating temperature range by cooling the transducer. In oneimplementation cooling of the transducer can be accomplished bycontacting the transducer subassembly with a fluid, for example, saline.In some implementations the transducer can be cooled using a fluidhaving a lower temperature relative to the temperature of thetransducer. In one implementation a fluid for cooling the transducer isflushed past the transducer subassembly from a lumen in the catheter(see e.g., FIG. 2). Accordingly, as shown in FIG. 1, the proximal end ofa lumen of the catheter 110 can be connected to a fluid port 162, forexample, a luer fitting, in the proximal housing 122. As further shownin FIG. 1, in one implementation fluid used for cooling the transducercan exit the catheter tip 112 through a one or more apertures 164. Theapertures can be a grating, screen, holes, weeping structure or any of anumber of suitable apertures. In one implementation apertures 164 aredrip holes.

Referring to FIG. 2, in one implementation where the elongate member ofthe device is a catheter, the shaft of the catheter 110 includes amulti-lumen tubing 170 having one or more lumens 176, which is encasedin a braid 166 of suitable metallic or non-metallic filaments and isencased in a smooth jacket 168 made of conventional biocompatiblematerial. Lumens 176 can accommodate any of a number of features of theinvention including but not limited to, pull wires, fluids, gases, andelectrical connections.

In FIGS. 3A-C, an exemplary series of drawings illustrate bending of thecatheter distal portion in more detail. In the implementation shown, thedistal pull wire 116 is secured at a distal portion of the tip assembly112 by means of the distal adhesive band 118. In use, as the distal pullwire 116 is pulled by moving the first slider 120 (see FIG. 1), thecatheter distal portion is bent at location 126 in the direction 172,thereby moving from position X to position Y, as shown in FIG. 3B. Next,the proximal pull wire 128, which is secured in the catheter lumen at aposition by proximal adhesive band 130, is pulled by moving the secondslider 132 (see FIG. 1). This results in the catheter 110 distal portionbending at location 136 and moving in the direction 174 to position Z,away from the longitudinal axis of the catheter, as shown FIG. 3C.

It is envisioned that the pull wire attachment points, andcorrespondingly the bend locations in the device can be configured, inany of a number of ways, not limited to the examples described herein.For example, it is envisioned that a single pull wire or other bendinducing mechanism can be used. Alternatively, the use of three or moresuch mechanism is envisioned. With respect to attachment points for bendinducing mechanism, it is envisioned that any location along the distaltip assembly as well as the catheter distal portion are suitableoptional attachment points. With respect to the number and location ofbend locations in the device, it is envisioned that a spectrum ofsuitable bend locations can be provided. For example, while one and twobends are illustrated herein, it is envisioned that three or more bendscan be used to achieve a desired catheter configuration and/orapplication of energy using the device.

The anchor mechanism 140 of the device can be deployed in a separate orsimultaneous step from bending the device, as shown in FIG. 3D. Theanchor mechanism 140, which can be configured to reside in a lumen (notshown) of the catheter 110, is advanced out of the catheter 110 andthrough the anchor notch 142 by moving the third slider 148 (see FIG.1). In the implementation shown in FIG. 3D, as the anchor mechanism 140exits the notch 142 a distal portion of the mechanism 140 takes on thepre-formed shape of a loop 138. This loop 138 is advanced further inaxial direction 144 until it firmly engages tissue, for example in theinside wall of a tissue chamber such as the left atrium of the heart.The anchor mechanism provides a rotational axis for the distal tipassembly. The transducer subassembly 114 can be intentionally displacedaway from this axis so that when the catheter shaft is rotated (seearrow 152) around the axis provided by the anchor mechanism 140, thetransducer can traverse a substantially circular loop inside the tissuechamber. The result of this motion is to create a substantially circularablation zone inside the tissue chamber (described in more detail inFIG. 11). It is envisioned that an arc-shaped or other curved ablationzone could alternatively be created with the device.

The design of the distal tip subassembly can include a variety ofconfigurations providing alternative means of delivering energy totissue. A first embodiment of the distal tip subassembly 1112 is shownin FIG. 4. As illustrated, the tip assembly 1112 can include a closedend tube casing 1142 which is transparent to ultrasound waves. It canfurther contain a transducer subassembly 1114 including an ultrasoundtransducer 1120. The transducer 1120 can be made of a piezoelectricmaterial such as PZT (lead zirconate titanate) or PVDF (polyvinylidinedifluoride) and the like. The transducer 1120 can be configured as adisc and the faces of the disc can be coated with a thin layer of ametal such as gold. In one implementation the disc is a circular flatdisc. Other suitable transducer coating metals include but are notlimited to stainless steel, nickel-cadmium, silver or a metal alloy. Asshown in FIG. 4, in one implementation the transducer 1120 can beconnected to electrical attachments 1130 and 1132 at two opposite faces.These connections can be made of insulated wires 1134 which can be, forexample, a twisted pair or a coaxial cable so as to minimizeelectromagnetic interference. When a voltage is applied across thetransducer, ultrasonic sound beam 1158 is emitted. The frequency of theultrasound beam is in the range of about 1 to 50 megaHertz.

As shown in FIG. 4, a temperature sensor 1136 can be coupled with thetransducer 1120, for example, attached to the back face of thetransducer 1120. The temperature sensor can be comprised of athermocouple or a thermistor or any other suitable means. As shown inFIG. 4, the sensor 1136 can include wires 1138 which carry thetemperature information to the catheter proximal end. The wires 1134 and1138 together can form a wire bundle 1140 extending to the catheterproximal end.

As further shown in FIG. 4, the transducer 1120 can be attached to abacking 1126 by means of an adhesive ring 1122 or other attachment,which creates a void or pocket 1124 between the transducer 1120 and thebacking 1126. The pocket 1124 can include a material which efficientlyreflects sound waves generated by the transducer 1120. The material ofthe pocket 1124 can be air or any other suitable material such as metalor plastic which reflects the sound waves. Advantageously, the soundwaves thus can be directed to exit from the front face of thetransducer, resulting in a minimum amount of sound energy lost outthrough the transducer back face into the backing. The backing can bemade of a thermally conductive material such as metal or plastic foraiding in the dissipation of heat which is created when the transduceris energized.

As illustrated in FIG. 4, the wire bundle 1140 can be fed through apassageway or hole 1128 in the backing 1126 and can be housed in a lumenof the catheter 1110. The wire bundle can terminate in the connector 156at the proximal housing 122 (see FIG. 1). As shown in FIG. 4, theproximal end of the backing 1126 can be secured to the casing 1142 bymeans of the distal adhesive band 1118. This creates a void or chamber1146 between the distal end of the casing 1142 and the distal adhesiveband 1118. The chamber 1146 is configured to be filled with a thermallyconductive fluid such as saline so that the transducer 1120 can becooled while energized. The distal adhesive band 1118 can include apassageway 1148 which is used in connecting the chamber 1146 to a fluidcarrying lumen. The passageway 1148 can be in fluid communication withthe fluid port 162 at the proximal housing 122 through one of the lumens(not shown) of the catheter 1110 (see FIGS. 1 and 4). As shown in FIG.4, the chamber 1146 can include one or more apertures 1164, for example,drip holes distributed circumferentially at the chamber 1146 distalportion. In use, prior to insertion of the device into the body, thechamber can be filled with a fluid such as saline. This can beaccomplished using a suitable fluid supply device such as a syringeconnected to the fluid port (not shown). The fluid from the syringe canflow through the passageway of the distal adhesive band, into thechamber while expelling the air out from the chamber through theapertures. During the use of the device in the body, a constant drip ofsaline can be maintained, if necessary, to cool the transducer.

Still referring to FIG. 4, a distal pull wire 1116 can be secured to thedistal tip subassembly 1112 by the distal adhesive band 1118. The distalpull wire 1116 can reside in one of the lumens 1176 of the catheter 1110and can be connected to the slider 120 in the proximal housing 122 (seeFIG. 1 and FIG. 4). As described above in reference to FIG. 3A, thedistal pull wire 1116 can be utilized in bending the distal portion ofthe catheter 1110. As shown in FIG. 4, the distal tip subassembly 1112can be securely attached to the catheter tubing 1170 of the catheter1110 by the proximal adhesive band 1144. As further shown in FIG. 4,lumens 1176 of the catheter tubing 1170 can be utilized for passage ofvarious elements of the tip subassembly 1112 and any of their relatedfeatures, in addition to instruments, gases, fluids, or othersubstances.

A second embodiment of the invention including an alternative distal tipassembly arrangement is shown in FIG. 5. Here the transducer subassembly1214 is mounted in the distal tip assembly 1212 such that the ultrasoundtransducer 1220 face is substantially parallel to the longitudinal axisof the catheter 1210 (that is to say the longitudinal axis of thecatheter 1210 before bending the distal tip assembly 1212 or catheter1210). In this configuration, the sound beam 1258 exits from a lateralsurface of the tip assembly 1212. The construction of the catheter inthis configuration can be essentially same as that described herein forthe first embodiment (see FIGS. 1-4).

As shown in FIG. 5, the distal tip assembly 1212 and catheter 1210 bendpoints, distal bend location 1272 and proximal bend location 1274respectively, can be arranged and configured such that the ultrasoundbeam 1258 is presented to the tissue 146 in a substantially right anglefrom the catheter 1210 longitudinal axis. In this manner an ablationzone 1260 is produced laterally through the tip assembly 1212. FIG. 6shows details of the distal tip assembly 1212 for this embodiment. Asillustrated, the tip assembly 1212 can be assembled in a tube 1242 whichis substantially transparent to the ultrasound waves 1258. Thetransducer subassembly 1214 can include a transducer 1220 which haselectrical connections 1230 and 1232 on opposite flat faces. Asdiscussed herein, the transducer 1220 can include a temperature sensor1236 on, for example, a back side which has wire connections. Thetransducer wires and the temperature sensor wires together form a bundle1240 which resides in a lumen 1276 of the catheter tubing 1270.

Still referring to FIG. 6, the distal end of the tube housing 1242 canbe sealed. As shown in FIG. 6, in one implementation the distal end issealed with a thermally conductive adhesive 1250. The back side of thetransducer subassembly 1214 can be secured to an adhesive ring 1222 thatis connected to a backing 1226. Thus, a void or pocket 1224 is createdbetween the transducer 1220 and the backing 1226. As shown in FIG. 6,the backing 1226 can be secured to the inner wall of the tube 1242, forexample, by the distal adhesive band 1218. There can be a passageway1248 in the adhesive band 1218 to allow the flow of a fluid such assaline to be introduced into the chamber 1246. The passageway 1248 canbe in fluid communication with the fluid port 162 at the proximalhousing 122 of the catheter 1210 (see FIGS. 1 and 6). As discussedherein the chamber 1246 can include a number of apertures 1264, forexample, drip holes distributed circumferentially at the chamber 1246distal end. As further described herein, prior to insertion of thedevice into the body, the chamber 1246 can be filled with a fluid suchas saline. In addition, during the use of the device in the body, aconstant drip of saline can be maintained, as required to cool thetransducer 1220.

Again referring to FIG. 6, a distal pull wire 1216 can be secured to thedistal tip subassembly 1212 by the distal adhesive band 1218. The distalpull wire 1216 can reside in one of the lumens 1276 of the catheter 1210and can be connected to the slider 120 in the proximal housing 122 (seeFIG. 1 and FIG. 6). As described above in reference to FIG. 3A, thedistal pull wire 1216 can be utilized in bending the distal portion ofthe catheter 1210. As shown in FIG. 6, the distal tip subassembly 1212can be securely attached to the catheter tubing 1270 of the catheter1210 by the proximal adhesive band 1244. As further shown in FIG. 6,lumens 1276 of the catheter tubing 1270 can be utilized for passage ofvarious elements of the tip subassembly 1212 and any of their relatedfeatures, in addition to instruments, gases, fluids, or othersubstances.

A third embodiment of the invention including an alternative distal tipassembly arrangement is shown in FIG. 7. Various details, features anduses of this embodiment include those as described herein regardingother embodiments. In this embodiment an alternative transducersubassembly is provided as shown in detail in FIG. 8. As shown in FIG.8, the ultrasound transducer 1320 can be mounted on an angled backing1326. The angle of the backing can range between substantially 0-90°. Inone implementation the angle is substantially 10-80°. In anotherimplementation the angle is substantially 30-60°. In anotherimplementation the angle is substantially 40-50°. In a furtherembodiment the angle is substantially 45°. The transducer can include ashape. In one implementation the transducer is in the shape of anelliptical disc. In another implementation the transducer has arectangular shape. As shown in FIGS. 7 and 8, in one implementation thetransducer 1320 can emit energy in the form of an ultrasound beam 1358at an angle to the longitudinal axis of the catheter 1310. As shown inFIG. 7, the ultrasound beam 1358 can be directed to the tissue 146 byappropriately bending the distal tip assembly 1312 using, for example,pull wires as described herein. The ultrasound energy beam 1358 cancreate an ablation zone 1360 in the tissue 146. Cooling of thetransducer in this implementation can be achieved as described herein.

As shown in FIG. 8 the angled backing 1326 can be secured in the distaltip assembly 1312 by the distal adhesive band 1318. It is envisionedthat other means of securing the backing to the distal tip assembly caninclude but are not limited to attachment using: adhesive, welding, pinsand/or screws or the likes. Still referring to FIG. 8, a distal pullwire 1316 can be secured to the distal tip subassembly 1312 by thedistal adhesive band 1318. The distal pull wire 1316 can reside in oneof the lumens 1376 of the catheter 1310 and can be connected to theslider 120 in the proximal housing 122 (see FIG. 1 and FIG. 8). Asdescribed above in reference to FIG. 3A, the distal pull wire 1316 canbe utilized in bending the distal portion of the catheter 1310. As shownin FIG. 8, the distal tip subassembly 1312 can be securely attached tothe catheter tubing 1370 of the catheter 1310 by the proximal adhesiveband 1344. As further shown in FIG. 8, lumens 1376 of the cathetertubing 1370 can be utilized for passage of various elements of the tipsubassembly 1312 and any of their related features, in addition toinstruments, gases, fluids, or other substances.

A fourth embodiment of the invention including an alternative distal tipassembly arrangement is shown in FIG. 9, and the details of the tipassembly are shown in FIG. 10. Various details, features and uses ofthis embodiment include those as described herein regarding otherembodiments. In this embodiment an alternative transducer subassembly isprovided as shown in detail FIG. 10. As shown in FIG. 10, in thisimplementation, the ultrasound transducer 1420 is mounted at a distalportion of the distal tip assembly 1412. Further, the transducer 1420 isdirected substantially toward the proximal direction. As illustrated, inthis orientation the transducer 1420 can emit an ultrasound wave 1457substantially parallel to the longitudinal axis of the distal tipassembly 1412.

As shown in FIG. 10, proximal to the transducer 1420 an angled reflectordevice can be mounted. For example, the reflector device can be acylindrical reflector 1452 with having a face cut at an angle to thedistal tip assembly 1412 longitudinal axis. The reflector 1452 can bearranged to reflect the ultrasound energy wave 1457 produced by thetransducer 1420 as an outgoing ultrasound wave 1458 which exits thetubing 1442 and travels to the intended ablation site 1460 in the tissue146. It is envisioned that the reflector can alternatively include anon-planar face, for example, a curved, convex or concave surface. Theangle of the reflector can range between substantially 0-90°. In oneimplementation the angle is substantially 10-80°. In anotherimplementation the angle is substantially 30-60°. In anotherimplementation the angle is substantially 40-50°. In a furtherembodiment the angle is substantially 45°.

The reflector 1452 can be secured to the tubing 1442 by means of thedistal adhesive band 1418 which can also secure the distal pull wire1416. The adhesive band 1418 can include a passageway 1448 for the flowof a cooling fluid as describe herein. The transducer subassembly 1414can be secured at the distal portion of the tip assembly 1412 by meansof thermally conductive adhesive 1450 which, together with the adhesiveband 1418 forms a chamber 1446. The chamber 1446 can include one or moreapertures 1464. As shown in FIG. 10, in one implementation the apertures1464 are drip holes distributed circumferentially about the distalportion of the distal tip assembly 1412.

In use, a cooling fluid can be flowed from the passageway 1448 in thedistal adhesive band, past the reflector 1452 and exit by way of theapertures 1464. This fluid flow can serve to cool the transducer 1420and keep it within nominal operating temperatures. It is envisioned thatcooling of the transducer can be controlled to provide nominaltransducer operation. As shown in FIG. 10, the transducer 1420 caninclude a temperature sensor 1436, for example, attached to the backside of the transducer. The temperature sensor 1436 can includeassociated lead wires, which along with the wires for the transducer canform a bundle 1440 which is subsequently contained in a lumen 1476 ofthe catheter tube 1470. Similarly, the fluid passageway 1448 can be influid communication with a lumen 1476 of the catheter tubing 1470. Asfurther shown in FIG. 10, the distal pull wire 1416 can also becontained in a lumen 1476 of the catheter tubing 1470. As shown in FIG.10, in one implementation tubing 1442 is bonded to the catheter tubing1470 by means of proximal adhesive band 1444.

Still referring to FIG. 10, a distal pull wire 1416 can be secured tothe distal tip subassembly 1412 by the distal adhesive band 1418. Thedistal pull wire 1416 can reside in one of the lumens 1476 of thecatheter 1410 and can be connected to the slider 120 in the proximalhousing 122 (see FIG. 1 and FIG. 10). As described above in reference toFIG. 3A, the distal pull wire 1416 can be utilized in bending the distalportion of the catheter 1410. As shown in FIG. 10, the distal tipsubassembly 1412 can be securely attached to the catheter tubing 1470 ofthe catheter 1410 by the proximal adhesive band 1444. As further shownin FIG. 10, lumens 1476 of the catheter tubing 1470 can be utilized forpassage of various elements of the tip subassembly 1412 and any of theirrelated features, in addition to instruments, gases, fluids, or othersubstances.

The anchoring mechanism of the device can be configured in any of anumber ways in addition to the mechanism as illustrated, for example inFIGS. 3 and 14 wherein a wire loop is included. One function of theanchor mechanism is to provide a firm axis of rotation to the catheteras it is rotated so that the ultrasound beam can be directed to providea partial or complete zone of ablation. Another function of the anchormechanism in some implementations is to provide stabilization of thecatheter when manipulating the catheter distal portion. As shown in FIG.14 the anchor mechanism 140 can include a wire loop 138 that can befirmly pressed against the ceiling wall of a heart chamber.

As shown in FIG. 15, in another implementation anchor mechanism 370including an expandable member, for example, an inflatable balloon isprovided. The anchoring member can be in the shape of a disc 372 that isinflatable, for example, an inflatable balloon. The shaft of the anchormechanism 370 in this case can be made of a suitable tubing 374 forinflating and deflating the disc 372. The disc can be constructed suchthat when in a deflated profile, the disc can move through an assignedlumen in the catheter (not shown). In use, the device is placed in aheart chamber as described herein. The implementation of the anchormember 374 illustrated in FIG. 15 can be advanced beyond the notch 342,and after deployment the disc 372 can be inflated. The inflated disc canbe firmly pressed against the ceiling wall of the heart chamber (notshown). The shaft 374 of the anchor mechanism 370 in this implementationprovides an axis of catheter rotation 352 around which the distal tipassembly can be rotated to sweep the ultrasound energy beam to create azone of ablation. Anchor mechanism 370 shown in FIG. 15 can be withdrawninto the catheter by deflating the disc and pulling the anchor mechanism370 proximally into the lumen through the notch 342, for example, byactuating a slider mechanism provided at the proximal housing of thecatheter.

Although the disc 372 of this anchor mechanism 370 implementation isdescribed as a balloon (see FIG. 15), it is envisioned that any type ofexpandable member could be used. Suitable expandable members can includebut are not limited to a cage, stent, or other self-expanding devicethat can be deployed and collapsed as required. Such structures are wellknown in the art.

Another implementation of an anchor mechanism is illustrated in FIG. 16.In this implementation, the distal portion of the anchor mechanism 470includes one or more barb members 472 or similar tissue engaging hooks.As the anchor mechanism 470 is deployed by advancing the mechanism 470distally beyond the catheter notch 442, the barb members 472 deploy toan open configuration. Upon further advancement of the anchor mechanism,the barb members can engage firmly in the tissue, for example theceiling wall of the heart chamber (not shown). Again, as shown in FIG.16, the shaft 474 of the anchor mechanism 470 provides an axis ofrotation 452 for the catheter 410 when the catheter 410 is used forcreating a zone of ablation. The barb members 472 can collapse as theanchor mechanism 470 is withdrawn into a lumen of the catheter by way ofthe notch 442, for example, by actuating a slider mechanism at theproximal housing of the catheter.

In general, in another aspect, an ablation device including a catheterhaving a distal tip assembly as described herein, but without a need forphysical anchoring to the ceiling wall of the heart chamber is provided.As shown in FIG. 17, in one implementation, the anchor mechanism 570 ofthe ablation device includes a double wall tubing 580 having an annulus582 between an inner wall 584 and an outer wall 586. Anchor mechanism570 is an elongate structure spanning from a distal portion of theablation catheter (see FIG. 17) to substantially the proximal portion ofthe device (not shown). The distal portion of the anchor mechanism 570includes an expandable member, for example, an inflatable balloon 588(see FIG. 17) which can communicate with a connector, for example, aluer fitting at the proximal end of the anchor mechanism 570 (notshown). Although a balloon is described as an exemplary expandablemember, it is envisioned that other expandable members including but notlimited to a cage or stent can be used. The inner lumen 590 of theanchor mechanism 570 provides a passageway for the ablation catheter 510such that the catheter is free to move axially 554 and radially 552within. As shown in FIG. 17, during use, the anchor mechanism 570 can bepositioned inside the guide catheter 522 and advanced distally until adistal portion of the anchor mechanism 570 extends beyond the guidecatheter 522 while the balloon 588 remains inside the guide catheter 522substantially proximal to the guide catheter 522 end. In anotherimplementation at least a part of the expandable member of the anchormechanism remains inside the guide catheter, while another part of theexpandable member extends distally beyond the guide catheter end (notshown). In yet another implementation the distal portion of the anchormechanism remains substantially proximal to the distal end of the guidecatheter (not shown).

To effect anchoring, the balloon can be inflated with a suitable fluid(e.g., saline or CO.sub.2) sufficiently such that a distal portion ofthe anchor mechanism is held firmly in the guide catheter. The ablationcatheter 510 can then be advanced distally (see arrow 554 in FIG. 17)through the inner lumen 590 of the anchor 570. As shown in FIG. 17, whenthe balloon 588 is inflated, the distal portion of the catheter 510exiting from the anchor mechanism 570 is free to rotate in a manner 552about a longitudinal axis, yet is held firmly in the guide catheter 522.As required, the catheter distal portion can be shaped by bending asdescribed herein to a desired position (e.g., see FIGS. 3A-C). Whenanchored at the end of the guide catheter, the distal portion of theablation catheter can be caused to follow a fixed rotational pathwithout being susceptible to wavering or wandering as the catheter isrotated or otherwise guided in the heart chamber to create a zone ofablation.

The creation of a zone of ablation is facilitated by moving the distalportion of the catheter sufficiently away from the longitudinal axis ofthe catheter followed by rotation around an axis of rotation provided byan anchor mechanism. The location and orientation of the distal tipassembly, and the resulting direction of the ultrasound energy beam, isdetermined by the bending of the catheter distal portion at one, two ormore locations along the catheter. In one implementation an ultrasoundbeam is presented to the tissue at a substantially orthogonal angle toachieve efficient ablation of the tissue. The direction of the soundbeam can be adjusted by manipulating the bending of the catheter distalportion. This can be achieved by presenting the beam to the tissue in aduty cycle manner where the beam is energized for a pre-determinedperiod followed by a quiet period. During this quiet period, a portionof the sound beam is reflected by the tissue, and the intensity of thereflection is measured by the same transducer being used in a receivemode. An operator or a control system can manipulate the angle of theultrasound energy beam to maximize the intensity of the reflected soundbeam. This ensures that the beam is substantially orthogonal to thetissue. As the beam is swept along the tissue, the distal tip assemblyangle can be continuously manipulated such that the beam is presented tothe tissue in a substantially orthogonal manner at all times. This canbe achieved by a microprocessor controlled system (not shown) whichutilizes the information provided by the reflected signal and thenmanipulates the tip bending through the pull wires connected toappropriate stepping motors. The motor mechanism can be contained in aseparate module connected to the generator by means of an electricalcable (not shown). The proximal housing of the ablation catheter can bearranged to engage with the motor module making appropriate connectionsbetween the slider mechanisms and the corresponding motors (not shown).The resulting zone of ablation would then achieve maximum ablation, andthe irregular anatomy, if any, of the heart chamber would be effectivelyaddressed.

It is envisioned that a zone of ablation produced using the devicedescribed herein can be lesion in tissue having a shape including butnot limited to a ring, elliptical, linear, and curvilinear as created bya combination of bending and/or rotating motions of the device.

In general, in another aspect, methods of using the embodimentsdescribed herein, for example, in treating atrial fibrillation, areprovided. By way of example, a use of the device of the first embodimentis illustrated in FIG. 11. One method of using the device can includethe following steps:

1. A guide catheter sheath 222 is positioned across the atrial septum224 of a heart in a conventional way. One such technique is described byGill (J. S. Gill, How to perform pulmonary vein isolation, Europace 20046(2):83-91). The opening of the guide catheter 222 is directed towardsthe ceiling 226 of the heart chamber.

2. Ablation catheter 210 is advanced through the guide catheter 222 andbeyond the guide catheter 222 open end towards the tissue area in themiddle of the pulmonary veins (PV) such that the distal tip assembly 212points generally towards a part of the tissue surrounded by the PV.

3. Anchor mechanism 240 is deployed from within the catheter 210 andwire loop 238 is securely positioned against the tissue of the ceiling226 of the heart chamber thereby providing an axis of rotation for thecatheter 210.

4. Tip assembly 212 of the catheter 210 is moved away from the wire loop238 by using the bending mechanism described herein and as shown FIGS.3A-C. In general, the distal pull wire 116 is pulled by moving the firstslider 120 (see FIG. 1), the catheter distal portion is bent at location126 in the direction 172, thereby moving from position X to position Y,as shown in FIG. 3B. Next, the proximal pull wire 128, which is securedin the catheter lumen at a position by proximal adhesive band 130, ispulled by moving the second slider 132 (see FIG. 1). This results in thecatheter 110 distal portion bending at location 136 and moving in thedirection 174 to position Z, away from the longitudinal axis of thecatheter, as shown FIG. 3C. In this way a portion or all of the tipassembly 212 can be positioned outside an area circumscribing the PV.More specifically, it is envisioned that the tip assembly 212 can bepositioned suitably, in terms of distance and incident angle (e.g.,orthogonal), to ablate tissue outside of an area defined by the PV.

5. The tip assembly 212 is oriented towards the tissue 226, and thedevice is energized by a generator (not shown) to provide a beam 258 ofemitted ultrasound energy which impinges on the tissue 226. This energybeam 258 creates an ablation zone 260 in the tissue 226.

6. The treatment of the tissue is continued until a complete ablation oftransmural thickness is achieved.

7. Catheter 210 is progressively rotated in a manner 252 about an axisas indicated in FIG. 11, such that the tip assembly 212 and the soundbeam 258 traverses in a substantially circular path in the heart chamber(indicated as dashed lines 262 in FIG. 11). The treatment of tissuealong a tissue path is continued until a complete ablation of transmuralthickness is achieved along the entire path to create a partial or acomplete zone of ablation 262 around all the targeted pulmonary veins,thereby achieving a conduction block.

8. The anchor mechanism 240 is retracted into a lumen through the notch242 by actuating the appropriate slider mechanism at the proximalhousing (not shown).

9. Distal tip assembly 212 is returned to a relaxed position byreleasing the pull tension on the respective pull wires (not shown)thereby readying the catheter 210 for retraction into the guide catheter222.

10. The ablation catheter 212 and the guide catheter 222 are removedfrom the body.

The method outlined above provides for a zone of ablation, having ashape as described herein, around four pulmonary veins. However, asshown in FIG. 12, in another method of using the device a conductionblock can be achieved by providing two zones of ablation, for example,ablation rings 264 and 266, each around two PV. Alternatively, anablation ring 268 can be placed around three PV as shown in FIG. 13. Itis envisioned that any combination of ablation zones including but notlimited to rings could be placed around one, two, three, or fourpulmonary veins to achieve a complete conduction block.

In another implementation a method of using the device described hereincan include the following steps:

1. A guide catheter sheath 222 is positioned across the atrial septum224 of a heart in a conventional way. The opening of the guide catheter222 is directed towards the ceiling 226 of the heart chamber.

2. Ablation catheter 210 is advanced through the guide catheter 222 andbeyond the guide catheter 222 open end towards the tissue area in themiddle of the pulmonary veins (PV) such that the distal tip assembly 212points generally towards a part of the tissue surrounded by the PV.

3. Tip assembly 212 of the catheter 210 is moved away from the wire loop238 by using the bending mechanism described herein and as shown FIGS.3A-C. In general, the distal pull wire 116 is pulled by moving the firstslider 120 (see FIG. 1), the catheter distal portion is bent at location126 in the direction 172, thereby moving from position X to position Y,as shown in FIG. 3B. Next, the proximal pull wire 128, which is securedin the catheter lumen at a position by proximal adhesive band 130, ispulled by moving the second slider 132 (see FIG. 1). This results in thecatheter 110 distal portion bending at location 136 and moving in thedirection 174 to position Z, away from the longitudinal axis of thecatheter, as shown FIG. 3C. In this way a portion or all of the tipassembly 212 can be positioned outside an area circumscribing the PV.More specifically, it is envisioned that the tip assembly 212 can bepositioned suitably, in terms of distance and incident angle (e.g.,orthogonal), to ablate tissue outside of an area defined by the PV.

4. Anchor mechanism 240 is deployed from within the catheter 210 andwire loop 238 is securely positioned against the tissue of the ceiling226 of the heart chamber thereby providing an axis of rotation for thecatheter 210.

5. The device is energized by a generator (not shown) to provide a beam258 of emitted ultrasound energy which impinges on the tissue 226. Thisenergy beam 258 creates an ablation zone 260 in the tissue 226.

6. The treatment of the tissue is continued until a complete ablation oftransmural thickness is achieved.

7. Catheter 210 is progressively rotated in a manner 252 about an axisas indicated in FIG. 11, such that the tip assembly 212 and the soundbeam 258 traverses in a substantially circular path in the heart chamber(indicated as dashed lines 262 in FIG. 11). The treatment of tissuealong a tissue path is continued until a partial or a complete zone ofablation of transmural thickness is achieved along the entire path tocreate complete ablation, for example, shaped as a ring 262 around allthe targeted pulmonary veins, thereby achieving a conduction block.

8. The anchor mechanism 240 is retracted into a lumen through the notch242 by actuating the appropriate slider mechanism at the proximalhousing (not shown).

9. Distal tip assembly 212 is returned to a relaxed position byreleasing the pull tension on the respective pull wires (not shown)thereby readying the catheter 210 for retraction into the guide catheter222.

10. The ablation catheter 212 and the guide catheter 222 are removedfrom the body.

In a further implementation, wherein the anchor mechanism of the deviceis the mechanism as shown in FIG. 17 and as described herein, a methodof using the device can include the following steps:

1. Referring to generally to FIG. 11 (disregarding the anchor mechanism240 depicted therein), a guide catheter sheath 222 is positioned acrossthe atrial septum 224 of a heart in a conventional way. The opening ofthe guide catheter 222 is directed towards the ceiling 226 of the heartchamber.

2. Referring now to FIG. 17, anchor mechanism 570 is advanced throughthe guide catheter 522 and beyond the guide catheter 522 open endtowards the tissue area in the middle of the pulmonary veins (PV) (notshown) such that the anchor mechanism 522 points generally towards apart of the tissue surrounded by the PV.

3. Referring still to FIG. 17, the balloon 588 of the anchor mechanism570 is inflated with a fluid such that a distal portion of the anchormechanism 570 is held firmly in the guide catheter 522.

4. The ablation catheter 510 is advanced through the inner lumen 590 ofthe anchor mechanism 570 and into the heart chamber.

5. Referring generally again to FIG. 11 (disregarding the anchormechanism 240 depicted therein), the tip assembly 212 of the catheter210 is bent into a shape using the bending mechanism described hereinand as shown FIGS. 3A-C. Thus, a portion or all of the tip assembly 212is positioned outside of an area circumscribing the PV.

6. The device is energized by a generator (not shown) to provide a beam258 of emitted ultrasound energy which impinges on the tissue 226. Thisenergy beam 258 creates an ablation zone 260 in the tissue 226.

7. The treatment of the tissue is continued until a complete ablation oftransmural thickness is achieved.

8. Referring again to FIG. 17, catheter 510 is progressively rotatedabout an axis in a manner 552 such that the tip assembly and the soundbeam traverses in a substantially circular path in the heart chamber(indicated as dashed lines 262 in FIG. 11). The treatment of tissuealong a tissue path is continued until a partial or a complete ablationof transmural thickness is achieved along the entire path. Thus, acomplete ablation ring 262 is made around all the targeted pulmonaryveins, thereby achieving a conduction block.

9. The catheter 512 is returned to a relaxed position by releasing thepull tension on the respective pull wires (not shown) and the catheter510 is retracted through the anchor mechanism.

10. The balloon 588 of the anchor mechanism 570 is deflated and theanchor mechanism 570 is retracted through the guide catheter 522 and theguide catheter 522 is removed from the body.

In another implementation, the methods described herein can be used totreat the left atrial appendage of the heart. In this case, the methodcan include use of the ablation device as described herein to produce aconduction block circumscribing the atrial appendage. It is envisionedthat the atrial appendage can be treated alone or in conjunction withtreatment of the PV using the ablation device of the invention.

Referring to the embodiment of FIG. 18, the system consists of acatheter set 100, two positioning wires 2128 and 2130, and a guidesheath 2118. The catheter set 100 is composed of two catheters, atherapy catheter 2110 which is slideably contained in an outer catheter2112. Catheter 2110 consists of a housing 2114 which contains theultrasound transducer 2116. A more detailed description of the housing2114 is presented later in this specification. Catheter 2110 iscontained in the outer catheter 2112. The catheter 2112 is furthercontained in the transseptal guiding tube 2118. Catheter 2112 has threeindependent movements available. First, the catheter 2112 can moveaxially in the guide tube 2118 as depicted by 2120. The distal tip ofthe catheter 2112 is equipped to be bent in a manner 2122. Finally, thecatheter 2112 can be rotated in the guide sheath 2118 in a manner 2124.Catheter 2112 contains a lumen 2126 which houses the locating wiresprings 2128 and 2130. Wires 2128 and 2130 are independently movable inthe lumen 2126 of catheter 2112.

The elements of the catheter systems are positioned in the left atrium(LA) of the heart. The wires 2128 and 2130 are positioned in the leftpulmonary veins (LPV). The therapy catheter 2110, outer catheter 2112,and the distal portion of the guide sheath 2118 are positioned in thechamber of the left atrium. Other structures of the heart shown in FIG.18 are the mitral valve opening (MV), left atrial appendage (LAA), andright pulmonary veins (RPV).

At the proximal end, the various catheter elements are connected to avariety of controls in a connector console 2132. After placement in theseptum of the heart, the guide sheath 2118 is locked in position bymeans of the lever 2134. The locating wires 2128 and 2130 have markers129 and 131 respectively at their proximal ends. The locating wires 2128and 2130 are designed to be guided by hand by the surgeon, and after theintended positioning, are locked in by means of the lever mechanisms2136 and 2138 at the position of the markers 129 and 131. The linearmovement 2120 of the outer catheter 2112 is achieved by moving theslider 2140 which moves linearly in slot 2142. Once the desired positionof the catheter 2112 is achieved, the slider 2140 can be locked inposition. The rotational movement 2124 of the outer catheter 2112 isachieved by the gear mechanism 2144 and 2146. Gear 2144 is attached tothe proximal end of the outer catheter 2112. Gear 2144 is driven by thepinion 2146 which is attached to a motor (not shown). The bendingmechanism 2122 of the distal tip of the catheter 2112 is achieved bymeans of the pull wire 2148 which terminates in a slider mechanism 2150which is lockable once the desired position of the bending of thecatheter 2112 is achieved. All the motions described here can beachieved by hand or by using appropriate motors, linkages, and actuatorsin the console 2132.

Similar to the outer catheter 2112, the catheter 2110 also is providedwith three independent movements. First, the catheter 2110 can be movedaxially in the catheter 2112 as shown by movement 2152. This movement2152 is controlled at the proximal end by means of the slider 2158 whichis lockable once the desired position of the therapy catheter 2110 isachieved in the outer catheter 2112. Second, the distal portion of thecatheter 2110 can be bent in the manner 2124 by means of a pull wire(not shown) connected to the slider mechanism 2160 at the proximal endconsole 2132. Again, the slider 2160 is lockable in position once thedesired position of the bend of the tip of the catheter 2110 isachieved. Finally, the catheter 2110 can be rotated in the outercatheter 2112 in a manner shown as 2156. This motion is effected by thegear mechanism 2162 and 2164 in the console 2132. Gear 2162 is attachedto the proximal end of the catheter 2110, and it is driven by the pinion2164 which is connected to a motor (not shown). The catheters 2110 and2112 contain the corresponding orientation marks 2166 and 2168 providedon the shafts thereof. The console also consists of a connector 2170which electrically connects to a power generator and controller (notshown). The connector 2170 also provides electrical connections to thepositioning wires 2128 and 2130 by means of being connected to thelocking levers 2136 and 2138 in the console 2132. As described later,the connector 2170 provides electrical connections to the ultrasoundtransducer 2116, a temperature sensor at the housing 2114, and thepositioning wires 2128 and 2130.

FIG. 36 shows the positions of the catheter elements in the left atrium.The locating wires 2128 and 2130 are positioned in the two pulmonaryveins (LPV1 and LPV2). As shown in the figure, the housing 2114 at thetip of the catheter 2110 points towards the wall tissue 2174 of theatrium. As described in detail later, the ultrasound element 2116 in thehousing 2114 emits an ultrasound beam to establish an ablation window2172. Now, as the outer catheter 2112 is rotated inside the guide sheath2118 in the manner 2124 and around the locating wires 2128 and 2130, theultrasound beam 2172 sweeps a generally circular path 2176 creating asection of a conical shell. The purpose of the two positioning wires2128 and 2130 is to assure that the rotation of the housing 2114 willoccur in a path outside the pulmonary vein LPV1 and LPV2. The objectiveof the invention is to find at least one such curve where the sweep path2176 of the ultrasound beam 2172 intersects with the atrial wall tissue2172 in a contiguous locus.

FIG. 20 shows the catheter apparatus. The therapy catheter 2110 and theouter catheter 2112 form a conjoined set 100 which can be freely movedaxially in the guide sheath 2118. The very tip section 186 of the sheath2118 has a snug fit over the outer catheter 2112 so as to provide a firmgrip on the catheter 2112 while it is performing its rotation 2124.Catheter 2112 can also be moved axially inside the guide sheath 2118 ina manner 2120. In addition, the tip of the catheter 2112 can be bentabout a pivot point 182 in a manner 2122. Catheter 2112 has a separatelumen 2126 which houses the locating wires 2128 and 2130. These wiresexit at the notch 127 and can be advanced or retracted in a manner 178and 180. The wires 2128 and 2130 are constructed from a material such asnitinol so as to take the shape of conical springs 194 and 196respectively when in free space. The ends of the positioning wires canalso be shaped in a suitable configuration other than the conical shapesdescribed herein. The tips 190 and 192 of the wires 2128 and 2130 aremade of a soft spring coil so as not to cause any injury to the tissueof the heart where the tips might be in contact and move against. Thewires 2128 and 2130 can be advanced in the atrial chamber with theintention of being positioned in the two pulmonary veins. The wires 2128and 2130, when residing completely inside the lumen 2126 of the catheter2112, are held in a generally straight shape conforming to confines ofthe lumen 2126 (ref. FIG. 23). As they are advanced outwards, and asthey exit the notch 127, they take on the predetermined shape of conicalsprings 194 and 196. The rotation 2124 of the catheter 2112 isessentially around the wires 2128 and 2130 with lumen 2126 serving asthe axis of said rotation.

As described earlier, the therapy catheter 2110 similarly has threedegrees of motion. It can move axially in the outer catheter 2112 in amanner 2152. Catheter 2110 can be bent in a manner 2154 around a pivotpoint 184. Finally, the catheter 2110 can be rotated in the manner 2156.The tip end 188 of the outer catheter 2112 has a snug fit over thecatheter 2110 to provide a firm support during the rotation 2156 of thecatheter 2110. Otherwise, the catheter 2110 is freely movable inside theouter catheter 2112 in a manner 2152.

The tip of the catheter 2110 has a housing 2114 which contains anultrasound transducer 2116. FIG. 21A shows the details of the housing2114. The transducer 2116, which is of a generally circular shaped discfabricated from a suitable piezoelectric material, is bonded to the endof a cylindrical backing 198 by means of an adhesive ring 200. Theattachment of the transducer 2116 to the backing 198 is such that thereis an air pocket 202 between the back surface of the transducer 2116 andthe backing 198. This air pocket 202 is useful in the sense that whenthe transducer 2116 is energized by the application of electricalenergy, the emitted ultrasound beam is reflected by the air pocket 202and directed outwards from the transducer 2116. The air pocket 202 canbe replaced by any other suitable material such that a substantialportion of the ultrasound beam is directed outwards from the transducer2116. Backing 198 can be made of a metal or a plastic, as shown in moredetail in FIG. 21B, such that it provides a heat sink for the transducer2116. The cylindrical backing 198 has a series of grooves 204 disposedlongitudinally along the outside cylindrical wall. The purpose of thegrooved backing is to provide for the flow of a cooling fluid 2224substantially along the outer surface of backing 198 and past the faceof the transducer 2116. The resulting fluid flow lines are depicted as206 in FIG. 21A. In an actual clinical situation, saline or any otherphysiologically compatible fluid can be used as the cooling fluid 2224at any safe temperature preferably below the body temperature of 37°Celsius.

The transducer 2116 has an electrical contact 208 on the front surfaceof the transducer using a suitably insulated wire 214. The electricalcontact 208 can be made by standard bonding techniques such as solderingor wire bonding. The contact 208 is preferably placed closer to the edgeof the transducer 2116 so as not to disturb the ultrasound beam 2226emitted by the transducer 2116 upon being electrically energized. Thefront face of the transducer 2116 is covered with another material knownas the matching layer 228. The purpose of the matching layer 228 is toincrease the efficiency of coupling of the ultrasound wave 2226 into thesurrounding fluid 2224. Generally, as the ultrasound energy moves fromthe transducer 2116 into the fluid 2224, the acoustic impedances aredifferent in the two media, resulting in a reflection of some of theultrasound energy back into the transducer 2116. A matching layer 228provides a path of intermediate impedance so that the sound reflectionis minimized, and the output sound from the transducer 2116 into thefluid 2224 is maximized. The thickness of the matching layer 228 ismaintained at one quarter of the wavelength of the sound wave in thematching layer material. There are a number of material candidates,generally from a family of plastics, which can serve as the matchinglayer. One such material is parylene which can be easily placed on thetransducer face by a vapor deposition technique. In addition one candeposit a multitude of matching layers, generally two or three, on theface of the transducer to achieve maximum energy transmission from thetransducer 2116 into the fluid 2224. Conversely, same reflectionprinciple is used on the backside of the transducer 2116. Here the airpocket 202 is provided. Ultrasound energy sees a large impedancemismatch, so a majority of energy is reflected back into the transducer2116 and emitted from its front face. Thus by using a combination of theair pocket 202 on the back and matching layer(s) 228 on the front, theefficiency of the transducer 2116 is greatly enhanced. Alternatively,the air pocket 202 could be replaced with a backing block material thatminimizes reflections from the behind the transducer 2116. While thisbacking block can reduce the amount of energy transmitted from the frontof transducer 2116, it removes reverberations and other artifacts whentransducer 2116 is operating as an ultrasound receiver. The backingblock material is designed to maximize the efficiency of transducer 2116while providing adequate suppression of imaging artifacts.

The back side of the transducer 2116 also has an electrical connection2210 to a suitably insulated wire 216. Again, the bonding can be done inany of the conventional manner such as a solder joint or wire bonding.Wires 214 and 216 together form a pair 218 which can be a twisted pairor miniature coaxial cable. On the backside of the transducer 2116,there is temperature sensor 2212. Its purpose is to monitor thetemperature of the transducer 2116 during its use. The sensor can be athermocouple or a thermistor of appropriate size so as to cover a smallportion of the transducer surface. Two wires 220 provide the electricalconnection to the temperature sensor 2212. The wire pairs 218 and 220form a bundle 2222. The flow of the cooling fluid is achieved through alumen 2242 which is terminated in a fluid port 254 at the proximal end(ref. FIG. 18).

The transducer-backing subassembly is encased in a tubular jacket 230.The material of the jacket can be metal or plastic. The tubular jacketprotrudes distally beyond the transducer 2116 to form a fluid chamber orpocket 236. This pocket 236 provides for a column of fluid 2224 which isin a physical and thermal contact with the transducer 2116. Thisinvention provides for the fluid column 2224 for two distinctobjectives. First, the column 2224 provides for the thermal cooling ofthe ultrasound transducer 2116. This column 2224 is at a lowertemperature than the transducer face and therefore aids in cooling thetransducer 2116. The temperature of the fluid 2224 can be easilycontrolled by providing the cooling fluid at a suitable temperature. Thetemperature of the transducer is constantly monitored by the temperaturesensor 2212 disposed on the back of the transducer 2116. Secondly, thefluid column provides for a separation medium between the ultrasoundtransducer 2116 and the blood surrounding the housing 2114 during theuse of the device in a clinical setting.

Still referring to FIG. 21A, the tubular jacket 230 is shown at itsdistal end in a “castle head” configuration with slots 239. The purposeof the slots 239 is to provide for exit ports for the flowing fluid2224. The slots 239 are desirable for the situation when the front tipof the catheter is in contact with the tissue or other structures duringthe use of the device, to maintain the important flow of the coolingfluid. The fluid flow lines 206 flow along the grooves 204, bathe thetransducer 2116, form the fluid column 236 and exit through the slots239 at the castle head 2238. The maintenance of the fluid flow throughthe tubular jacket 230 can be achieved in a number of different ways.One additional such way is shown in FIG. 21C where the tubular jacket230 consists of an enclosed chamber with small holes 2240 on thecylindrical surface closer to the distal end. These holes 2240 providefor the exit path for the flowing fluid.

It is important to maintain the transducer functioning at a lowertemperature so as to operate at a safe temperature for the patient, andto preserve consistent performance of the piezoelectric material, whichcan be damaged by exposure to excessive heat.

Another important function of the housing design of this invention is toprovide a barrier between the face of the transducer 2116 and the bloodresiding in the atrium of the heart. If the fluid flow is notincorporated, and the transducer face is directly in contact with blood,the blood will coagulate on the surface of the transducer 2116. Thecoagulation will be further aggravated if the transducer gets hotterduring its operation. The coagulated blood will provide a barrier totransmission of the ultrasound energy in an unpredictable way dependingon the coverage of the transducer face by the coagulated blood.Additionally, there is serious risk of forming a blood clot at theinterface of the transducer 2116 and the surrounding blood. Theincidence of any blood clot is undesirable in any situation in the heartchamber. The flow of the cooling fluid, as described in this invention,keeps the blood from getting in contact with the transducer face, thusavoiding the formation of blood clots. We have determined that a flowrate of approximately 1 ml per minute is sufficient to maintain thefluid column 236 and keep the separation between the blood and the faceof the transducer.

FIG. 21A shows the mounting of the transducer 2116 at an angle of 90degrees to the axis of the catheter housing 2114. However, thetransducer 2116 can also be mounted at any other angle. The exit path ofthe beam will be at 90 degrees to the face of the transducer. Theremaining details of the catheter and the presentation of the ultrasoundbeam to the tissue will vary accordingly in order to achieve theintended effect of tissue ablation.

The transducer disc 2116, as shown in FIG. 21A, has a flat frontsurface. This front surface of the transducer can be either concave orconvex to achieve an effect of a lens.

The tubular jacket 230 of the above description is attached to acatheter tubing 234 by means of adhesive 232. A pull wire 248 also issecured in the adhesive 232. The pull wire 248 is contained in a lumen244. This pull wire 248 is utilized in bending the tip of the catheter2110 in a manner 2154 (ref. FIG. 18). Another lumen 2242 provides thepath for the fluid flow. The wire bundle 2222 is contained in a yetseparate lumen 246 in the catheter tube 234.

Referring to FIG. 22 showing the cut-away section, the catheter tubing234 constitutes of a multilumen inner tubing 235 covered with a braid250 and a jacket 2252. The multilumen tubing 235 has three lumens. Thelumen 2242 is terminated in a fluid port 254 (ref. FIG. 18) at theproximal end of the catheter 2110. This allows the cooling fluid to bepassed through the length the catheter and exit at the ‘castle head’2238 of housing 2114. The lumen 246 contains the wire bundle 2222, andthe lumen 244 contains the pull wire 248. The tubing 2240 is encased ina braid 250 in a conventional way. The material of the braid can beround or flat metal wires, plastic filaments, or Kevlar. It isunderstood that the braid can be replaced with a spring like wrapping ora wrapping of foil. Finally, the braid 250 is covered in a smooth jacket2252. The material of the jacket is generally plastic, and can be placedusing conventional extrusion techniques. The braid 250 and the jacket2252 together provide the tortional control of the catheter tubing 234.The tortional control is required to achieve the rotation 2156 (ref.FIG. 18) of the therapy catheter 2110.

Next, the construction of the outer catheter 2112 is shown in a cut-awaysection in FIG. 23. The catheter tubing 256 consists of a multilumentubing 257 which is encased in a braid 2268 and a jacket 270. Themultilumen tubing 256 has three lumens, one lumen 2258 contains a pullwire 2260 which is terminated at the tip in an adhesive band 2262. Thispull wire is utilized in bending the outer catheter tubing in the manner2122 (ref. FIG. 18). Another lumen 2126 is provided for the positioningwires 2128 and 2130. The multilumen tubing 256 is encased in a braid2268 in a conventional way. The material of the braid can be round orflat metal wires, plastic filaments, or Kevlar. It is understood thatthe braid can be replaced with a spring like wrapping or a wrapping offoil. Finally, the braid 2268 is covered in a smooth jacket 270. Thematerial of the jacket is generally plastic, and can be placed usingconventional extrusion techniques. The braid 2268 and the jacket 270together provide the tortional control of the outer catheter tubing2112. The tortional control is required to achieve the rotation 2124(ref. FIG. 18) of the outer catheter 2112.

When energized with an electrical pulse or pulse train, the transduceremits a sound wave with properties determined by the characteristics ofthe transducer 2116, the matching layer 228, the backing 202, theelectrical pulse, and the tissue in front of the transducer. Theseelements determine the frequency, bandwidth and amplitude of the soundwave propagated into the tissue. Typically, the frequencies of theemitted sound are in the low megahertz range. For the intended use inthis invention, for tissue imaging and ablation near the transducer, theuseful frequencies range from 5 to 25 megahertz.

During one of the actual uses of the device of this invention, it willbe placed in the atrium of the heart. Referring to FIG. 24, thetransducer 2116 is maintained separated from the surrounding blood 284by a fluid column 236. When the transducer 2116 is energized with anappropriate electrical pulse, it emits a beam 272 of ultrasound energy.A typical beam pattern is shown for the ultrasound wave as it is emittedby the transducer 2116. This beam pattern illustrates the outline of theultrasound beam by mapping where the sound pressure falls by 6 dBrelative to the midline of the beam. The sound beam 272 travels in thedirection 274 away from the transducer 2116 in a generally collimatedmanner up to a distance of L and then diverges thereafter. The diameterat the origin of the ultrasound beam 272 corresponds to the diameter Dof the transducer disc 2116. If the device relies on the naturalfocusing of a flat disc transducer, the ultrasound beam 272 convergesslightly up to a depth of L, beyond which the beam diverges. The minimumbeamwidth D′ occurs at the distance L. It is well known that thedistance L is determined by the diameter of the transducer disc D andthe operating frequency. These relationships are well summarized byBushberg et al [The Essential Physics of Medical Imaging, 2nd edition,Bushberg, Seibert, Leidholdt and Boone, Lippincott Williams & Wilkins,2002; p. 491]. In this invention, a relatively large L is desired, sinceit establishes the size of the ablation window 2172. A variety of discdiameters and operating frequencies can be used. In general, D isselected as large as possible for a given device diameter, so that L ismaximized. A higher operating frequency will also increase the distanceL. However since ultrasound is attenuated in tissue as a function ofincreasing frequency, the required depth of the lesions determines theuseable maximum frequency. Given the constraints of device size andultrasound attenuation, this invention uses, for example, an operatingfrequency of 12 MHz and a disc diameter of 2.5 mm, resulting in a depthL of 12 mm and a minimum beamwidth D′ of 1.6 mm.

The natural focusing of a flat disc transducer provides adequate beamforming for typical uses of this invention. Adding an acoustic lens infront of transducer 2116 provides additional flexibility in adjustingthe beam pattern. For example, an acoustic lens could create a beam thatis more uniformly collimated, such that the minimum beamwidth D′approaches the diameter of the disc D. This will provide a more uniformenergy density in the ablation window 2172, and therefore more uniformlesions as the tissue depth varies within the window. A lens could alsobe used to move the position of the minimum beamwidth D′, for thoseapplications that may need either shallower or deeper lesion. This lenscould be fabricated from plastic or other material with the appropriateacoustic properties, and bonded to the face of transducer 2166.Alternatively, the circular piezoelectric disc could be fabricated witha front face that is curved instead of flat. A slight concave shape, forexample, would move the focal point (i.e. smallest D′) in towards thetransducer, while a slight convex shape would move the focus outwards.

The interaction of the ultrasound beam with the tissue is shown in FIG.25. The tissue 276 is presented to the ultrasound beam 272 within thecollimated length L. The front surface 280 of the tissue 276 is at adistance d (282) away from the face of the castle head 2238. As theultrasound beam 272 travels through the tissue 276, its energy isabsorbed by the tissue 276 and converted to thermal energy. This thermalenergy heats the tissue to temperatures higher than the surroundingtissue. The result is a heated zone 278 which has a typical shape of anelongated tear drop. The diameter D1 of the zone 278 is smaller than thebeam diameter D at the tissue surface 280. This is due to the thermalcooling provided by the surrounding fluid (cooling fluid 286 or blood284) which is flowing past the tissue surface 280. As the ultrasoundbeam travels deeper into the tissue, the thermal cooling is provided bythe surrounding tissue, which is not as efficient as that on thesurface. The result is that the ablation zone 278 has a larger diameterD2 than D1 as determined by the heat transfer characteristics of thesurrounding tissue as well as the continued input of the ultrasoundenergy from the beam 272. During this ultrasound-tissue interaction, theultrasound energy is being absorbed by the tissue, and less of it isavailable to travel further into the tissue. Thus a correspondinglysmaller diameter heated zone is developed in the tissue, and the overallresult is the formation of the heated ablation zone 278 which is in theshape of an elongated tear duct limited to a depth 288 into the tissue.

The interaction of ultrasound energy with the live tissue is wellstudied and understood. One such description is presented in the articleby Gail ter Haar “Acoustic Surgery, Physics Today, December 2001”. Inthe zone 278 where the tissue is heated, the tissue cells are rendereddead due to heat. The temperatures of the tissue typically are above 55°Celsius in the heated zone 278 and the tissue is said to be ablated.Hence, the zone 278 can be depicted as the ablation zone.

Referring to FIG. 25, it is important to present the tissue 276 to theultrasound beam 272 such that the tissue is within the collimated lengthL to achieve effective ablation. As the beam 272 is presented to thetissue for an extended period of time, the ablation zone 278 extendsinto the tissue, but not indefinitely. There is a natural limit of thedepth of the ablation zone 278 as determined by the factors such as theattenuation of the ultrasound energy, heat transfer provided by thehealthy surrounding tissue, and the divergence of the beam beyond thecollimated length L. This effect is beneficial in the sense that thereis a natural safety limit to the penetration of the ultrasound energysuch that the ablation zone 278 stops growing as a steady state isreached between the input of ultrasound energy and its conversion in tothermal energy which is dissipated by the surrounding tissue.

The ablation zone in the tissue is formed by the conversion of theultrasound energy to thermal energy in the tissue. The formation of theablation zone is dependent on time as shown in FIGS. 26 A-D, which showthe formation of the lesion at times t1, t2, t3 and t4, respectively. Asthe sound beam 272 initially impinges on the front surface 280 of thetissue 276 at time t1, heat is created which begins to form the lesion278 (FIG. 26A). As time passes on to t2, and t3 (FIGS. 26B and 26C, theablation zone 278 continues to grow in diameter and depth. This timesequence from t1 to t3 takes as little as 3 to 5 seconds, depending onthe ultrasound energy density. As the incidence of the ultrasound beamis continued beyond time t3, the ablation lesion 278 grows slightly indiameter and length, and then stops growing due to the steady stateachieved in the energy transfer from its ultrasound form to the thermalform. The example shown in of FIG. 26D shows the lesion after anexposure t4 of approximately 30 seconds to the ultrasound beam 272. Thusthe lesion reaches a natural limit in size and does not growindefinitely.

The ultrasound energy density determines the speed at which the ablationoccurs. The acoustic power delivered by the transducer divided by thecross sectional area of the beamwidth determines the energy density perunit time. In this invention, effective acoustic power ranges from 0.3watt to >10 watts, and the corresponding energy densities range from 3watts/cm.sup.2 to >100 watts/cm.sup.2. These energy densities aredeveloped in the ablation zone. As the beam diverges beyond the ablationzone, the energy density falls such that ablation will not occur,regardless of the time exposure.

One aspect of this invention is to provide a device which will producean ablation zone across the entire thickness of the wall of the atrialtissue in order to completely block the conduction of abnormalelectrical impulses. This is termed as a transmural lesion. Thetransmural lesion 279, as shown in FIG. 26C, is formed when the entirethickness of the tissue 276 is in the ablation window 2172, andsufficient time is allowed for the lesion to develop.

The dependence of the formation of the ablation zone 278 on the gapdistance 282 between the catheter tip and the tissue surface is shown inFIGS. 27A-D. For a uniformly collimated beam, as the gap distance 282increases, the depth 288 of the ablation zone 278 remains constant. Evenfor cases where the beam is not uniformly collimated, as in the case ofthis invention where the beam convergences slightly over distance L, thedepth 288 of the ablation zone 278 varies little as long as the tissueresides in an approximately collimated zone L. This distance L where theultrasound beam 272 is approximately collimated, and where an ablationzone is effectively created, is termed as the ablation window 2172.Thereafter the depth 288 decreases dramatically mainly due to thedivergence of the ultrasound beam 272.

In practice, the amount of beam convergence can be varied to partiallycompensate for tissue attenuation, thereby creating more uniform energydensities within the ablation window. This compensation helps reduce thevariations in depth 288 of the ablation zone 278 for tissues falling inthe ablation window 2172.

There is another important factor contributing to uniform ablationdepths 288 within the ablation window 2172 independent of the gapdistance 282. The sound beam travels through the cooling fluid and bloodin the gap 282 with very little attenuation. Therefore almost the entireacoustic energy is available and presented to the tissue 276 beginningat the front surface of the tissue 280.

For the practical use of the device of this invention, the discussion ofsome of the important parameters is presented. Above, we discussed thegap distance 282. The gap distance 282 is the distance between thedistal end of the castle head 2238 and the front surface 280 of thetissue 276. Now we discuss the angle of incidence as shown in FIGS. 28Aand 28B. The tissue 276 is presented to the ultrasound beam 272 suchthat its front face 280 is at an angles .theta.1 and .theta.2 to thebeam 272 at a gap distance 282. The resulting ablation 278 is formed inthe tissue in the line of the direction 274 of the beam travel. Theformation of the zone 278 is somewhat independent of the angle ofincidence .theta. Again, as long as the tissue 278 is presented to theultrasound beam 272 within the ablation window 2172, the resultingablation zone 278 profiles will be generally similar in shape, size, anddepth and somewhat independent of the incidence angle .theta.

In the actual clinical setting, the wall of the atrial tissue is movingwithin some physical distances. In order to achieve a contiguoustransmural lesion in the moving wall of the atrium, the entire movementmust be within the ablation window 2172. As shown in FIG. 29, the atrialwall tissue 276 is moving over a distance of R within the ablationwindow 2172. So long as the movement R is within the ablation window2172, an effective transmural lesion 278 will be created. Therefore itis important to position the castle head 2238 close enough to theendocardial surface of the atrial wall to ensure a transmural lesion ina moving wall.

One aspect of this invention is to present the ultrasound beam to theatrial tissue and move it across the tissue such that a contiguousablation zone (lesion) is created in the tissue wall. Referring to FIG.19, the zone 2172 depicts the cylindrical region in front of thetransducer 2116 where the atrial wall tissue 2174 is effectivelyablated. As the catheter 2112 is rotated in the manner 2124, the zone2172 sweeps in a circle creating a section 2176 of a cone. The catheterhousing 2114 can also be moved inside the atrium in geometry other thana circle by utilizing the various other movements available for thecatheters 2110 and 2112. Thus the sweeping ultrasound beam will form acomplex pattern 2176 inside the atrium. The atrial wall tissue 2174intersects this pattern 2176 forming a somewhat complex shaped lesion ofablated tissue. The important requirement for effective therapy is tocreate a contiguous transmural lesion which will serve as a conductionblock in stopping the aberrant electrical pathways in the atrium whichcause the fibrillation of atrial tissue.

Referring to FIG. 18, the ultrasound transducer 2116 is connected to anelectrical generator (not shown) by means of the connector 2170 whichcontains the wires 214 and 216 connected to the two faces of thetransducer 2116. When energized by the generator (not shown), thetransducer 2116 emits ultrasound energy at a frequency in the range of 1to 20 megaHertz (MHz). A practical range of frequency is 5 to 15 MHz. Itis well understood in physics of ultrasound, as the frequency increases,the depth of penetration of ultrasound energy in to the tissue isreduced resulting in an ablation zone 276 (ref. FIG. 25) of shallowerdepth 288. The energy of the ultrasound beam 272 is determined by theexcitation voltage applied to the transducer. The generator provides theappropriate frequency and voltage to the transducer to create thedesired sound beam 272. For the purpose of the description of thisinvention, we are using a frequency in the range of 5 to 15 MHz, and avoltage in the range of 10 to 100 volts peak-to-peak. In addition, avariable duty cycle can be used to control the average power deliveredto the transducer. The duty cycle ranges from 0% to 100%, with arepetition frequency of approximately 40 kHz, faster than the timeconstant of thermal conduction in the tissue. This results in anablation zone 278 which is created within 2 to 5 seconds, and is ofdepth 288 of approximately 5 millimeters (mm), and of a maximum diameterof approximately 2.5 mm in correspondence to the diameter of thetransducer 2116. It is understood that the ultrasound transducer ofdifferent diameters and frequencies can be used and different voltagesand duty cycles can be applied to get various outputs of ultrasoundpower resulting in different sized ablation zones 278.

A contiguous transmural lesion is intended as the ultrasound beam 272 isswept across the atrial wall. Therefore, it would be desirable to knowif a contiguous transmural lesion is indeed being created as theultrasound beam is moved across the moving atrial wall. This is achievedby using the same ultrasound transducer 2116 in a diagnostic mode asdescribed below.

The effectiveness of the creation of a transmural lesion 279 is inknowing and ensuring that the atrial wall tissue 2174 is being presentedto the ultrasound beam with the pattern 2176 for effective ablation(ref. FIG. 19). This is achieved by using the same ultrasound transducer2116 for the purpose of tissue detection. On the one hand, in order toachieve ablation (i.e. killing of the live tissue cells), the ultrasoundbeam of sufficient energy is delivered to the tissue in a substantiallycontinuous manner such that the energy input exceeds the thermalrelaxation provided by the cooling due to the surrounding tissue. Thismode of energizing the ultrasound transducer 2116 is termed as theablation mode. On the other hand, the tissue detection is done byutilizing a pulse of ultrasound of short duration which is generally notsufficient for heating of the tissue. Ultrasound has been traditionallyused for diagnostic purposes for a number of years. Typical uses arefetal ultrasound imaging, intravascular ultrasound imaging, and thelike. For the purpose of this invention, we use the ultrasound to detectthe gap (namely, the distance of the tissue surface from the castlehead), the thickness of the tissue targeted for ablation, and thecharacteristics of the ablated tissue. This mode of energizing thetransducer 2116 is termed as the diagnostic mode. One objective of thisinvention is to utilize the diagnostic mode in guiding the therapyprovided by the ablation of the tissue.

This invention uses a simple ultrasound imaging technique, referred toin the art as A Mode, or Amplitude Mode imaging. A short electricalpulse or train of pulses excites the ultrasound transducer creating ashort duration ultrasound pulse wave that propagates into the blood andtissue. As the ultrasound pulse travels through the tissue, some of theacoustic energy is backscattered to the transducer, which converts thereturning acoustic signal into an electrical voltage. The amplitude ofthe voltage is sensed in a receiver (not shown), as a function of thetime elapsed from the initial transmitted pulse. Since ultrasoundtravels through blood and soft tissue at a known and approximatelyconstant speed, the receiver can determine the distance from which thereturning signals originate. The amplitude of the returning signalsdepends on the acoustic properties of the tissue. Homogeneous tissuebackscatters the sound as the pulse wave propagates through it.Different tissues create differing amounts of backscatter, so thereturning ultrasound signal has different amplitudes depending on thetype of tissue. As the pulse travels passes from one tissue to another,a reflection occurs, the amplitude of which is determined by theacoustic impedance difference of the two tissues.

Referring to FIG. 30, the transducer 2116 sends a pulse 290 ofultrasound towards the tissue 276. A portion of the beam is reflectedand backscattered as 292 from the front surface 280 of the tissue 276.This reflected beam 292 is detected by the transducer 2116 a short timelater and converted to an electrical signal which is sent to theelectrical receiver (not shown). The reflected beam 292 is delayed bythe amount of time it takes for the sound to travel from the transducer2116 to the front boundary 280 of the tissue 276 and back to thetransducer 2116 now serving as an ultrasound detector. This travel timerepresents a delay in receiving the electrical signal from thetransducer 2116. Based on the speed of sound in the intervening media(saline fluid 286 and blood 284), the gap distance d (282) can bedetermined. As the sound beam travels further into the tissue 276, aportion 294 of it is reflected from the back surface and travels towardsthe transducer. Again, the transducer converts this sound energy intoelectrical signals and the generator converts this information into thethickness t (300) of the tissue 276 at the point of the incidence of theultrasound pulse 290. As the catheter housing 2114 is traversed in amanner 301 across the tissue 276, the ultrasound transducer continuouslydetects the gap distance d (282) and the tissue thickness t (300). Thisinformation is used in delivering continuous ablation of the tissue 276during therapy as discussed below.

The returning echo from tissue boundaries has the same time duration asthe transmitted pulse. The returning backscattered signal from the bulkof the tissue has a time duration equal to the path length of the pulsethrough the tissue. The returning signal from tissue 276 then is acomposite of two short relatively high amplitude pulses returning fromthe front wall 280 and back wall 298, along with the backscatter fromwithin the tissue. The amplitude of the backscatter from the tissue willchange as the pulse traverses the ablated tissue and the normal tissue.Therefore, by measuring the relative amplitudes of the returning signal,the receiver can determine the depth of the front wall, the depth of thelesion, residual tissue depth that is not yet ablated, and the depth ofthe back wall.

The receiver compares the time delay of the first echo from the face oftissue 280 to a time threshold corresponding to the ablation windowlength 2172. If the time delay is less than the threshold, thisindicates that the front face of the tissue 280 lies within the windowlength 2172. The receiver can indicate this by a display means, forexample lighting a ‘green’ display. If the receiver detects the echoarriving later than the time threshold, then a ‘red’ display can be litindicating that the gap 282 is too large, and a lesion may not becreated in the tissue.

The use of the above information in an actual clinical setting isdepicted in FIG. 31. The catheter 100 of catheters 2110 and 2112 isintroduced into the atrial chamber through the guide sheath 2118. Thepositioning wires 2128 and 2130 are advanced in to the two leftpulmonary veins LPV1 and LPV2. In the diagnostic mode, as the outercatheter 2112 is rotated in a manner 2124, the housing 2114 at the tipof the therapy catheter 2110 rotates in the atrial chamber. When thecatheter is in position A near the LPV1, the ablation window 2172intersects with the tissue wall 302. This indicates a condition that theablation of the tissue in its entire thickness can be achieved and isindicated by a ‘green’ light. As the housing 2114 continues to sweep theatrial chamber, it reaches position B near the LPV2. Here the ablationwindow 2172 does not intersect the tissue wall 304. This indicates acondition that the tissue is either too far, or the ultrasound beam ispointed towards a structure such as a PV, or the atrial appendage, orthe mitral valve opening. In this case, transmural ablation will not beachieved and a ‘red’ light will be indicated.

It is the objective of the user physician to establish a contiguous beampath 2176 (ref. FIG. 19) indicated by the ‘green’ light continuously litduring the movement along the entire intended lesion path. A check forthis continuous green light, before energizing the ultrasoundtransducer, will insure that the proposed path will result in acontiguous ablation zone in the atrial wall. The situation shown in FIG.31 does not yield a contiguous beam path, therefore the physician wouldmove the catheters 2110 and/or 2112 and sweep another circle of thehousing 2114 in diagnostic mode to arrive at a situation such as thatshown in FIG. 19. Once such contiguous path 2176 is established in thediagnostic mode, the physician can proceed with the ablation of the saidpath using the ablation mode.

As an added safety feature, the system can regularly, on a time-sharedbasis, convert from ablation mode briefly to diagnostic mode. In thisway, the correct gap can be checked even during the ablation. If the redlight goes on, the system will automatically exit the ablation mode,until a correct gap (i.e. green light) is again detected. Then theablation mode will be automatically resumed. This diagnostic samplingcan occur at a relatively fast sampling frequency. In the currentinvention, it occurs at about 40 kHz, corresponding to the duty cyclerepetition rate for the diagnostic power generator. Conversely, if the‘green’ light remains lit throughout the movement along entire ablationpath, then a contiguous lesion has been created. This measure offgoodness can result in an additional display (flashing ‘green’ light,for example) to inform the physician that he has created a completecontiguous lesion.

Furthermore, since the wall thickness and the lesion depth can also bechecked in the diagnostic mode on a time-shared basis during theablation, the system can dynamically control the lesion depth by varyingthe sweep rate along the intended ablation path, and/or changing thepower provided from the generator. In this way the lesion is even morelikely to be transmural contiguously all along the lesion path. Inaddition, the system can minimize the possibility of creating a lesionbeyond the atrial wall. If the system detects the lesion extendingbeyond the outer wall, the generator will be turned off. Alternatively,the system can be configured such that the generator is turned off whenthe depth of the lesion reaches or exceeds a preset depth.

The above description of the design and construction of the catheter set100 is aimed at creating the ablation zone for the left pulmonary veins.A different catheter set is used for the right pulmonary veins,essentially of the same functioning principles but of a differentgeometry appropriate for the anatomical location of the right pulmonaryveins in the left atrium of the heart. This catheter set 400 is shown inFIG. 32. The outer catheter 412 has a preset shape of a ‘shepherd'shook’ so as to point towards the right pulmonary veins when placed inthe atrial chamber. The catheter 412 can move in the axial direction inthe guide sheath 418 in a manner 420. The therapy catheter 2410 movesinside the outer catheter 412 in the axial direction in a manner 2452.In addition, catheter 412 can rotate in a manner 424. A lumen 426 (notshown) in the catheter 2410 is used to house the positioning wires 428and 430 which exit from the said lumen at the notch 427. The catheter2410 can also be rotated in the catheter 412 in a manner 456. The distaltip portion of the catheter 2410 can be bent by means of a pull wire(not shown) in the manner 454. The distal tip of the catheter 2410 iscomposed of a ‘castle head’ housing 414 which contains the ultrasoundtransducer 416. The transducer has an ablation window 2472 similar tothe ablation window 2172 (ref. FIG. 19) of catheter 2110. The additionalconstruction of the elements of the catheter 2410 are identical to thoseof the catheter 2110 as described earlier in this specification. Inaddition, the catheter set 400 engages with the console 2132 in asimilar manner as the catheter set 100.

Under the current state of knowledge, certain ablation lines are drawnin the atrium around the pulmonary veins in an attempt to block theconduction of aberrant electrical signals. This set of ablation lines iscalled a lesion set. In this invention, it is proposed to have a lesionset as shown in FIG. 33. One ablation ring 306 encircles the two leftPV's and another ablation ring 308 encircles the right PV's. An ablationline 3310 is drawn joining the ablation rings 306 and 308. Finally,another ablation line 312 is drawn intersecting the ablation line 3310and down to the annulus of the mitral valve (MV).

Next, a method for the use of the device of this invention in a clinicalsetting is presented as follows:

1. Referring to FIG. 18, position the guide sheath 2118 across theatrial septum S using the conventional femoral vein approach. Onetechnique for this procedure is described by Gill (J. S. Gill, How toperform pulmonary vein isolation, Europace 2004 6(2):83-91).

2. Pre-load the positioning wires 2128 and 2130 in the lumen 2126 of theouter catheter 2112 such that the distal tips of the wires are entirelyinside the lumen 2126.

3. Advance the catheter set 100 through the guide sheath 2118 into theatrial chamber.

4. Advance one of the positioning wire 2128 through the opening notch127 of the outer catheter 2112. The conical spring like shape 194 of thewire will now deploy. Under conventional fluoroscopic guidance, positionthe wire in the pulmonary vein LPV1. The wire can be rotated gently tohelp it find and navigate the ostium and the opening of the pulmonaryvein. Advance the wire slightly beyond the marker 129 at the proximalend to ensure its position inside the LPV1 then lock it in positionusing the lever 2136.

5. Advance the second positioning wire 2130, and guide its conicalspring 196 into to second vein LPV2 in a similar manner., positioning itbeyond the marker 131 at its proximal end and lock in position using thelever 2138.

6. Referring to FIG. 34, move the outer catheter 2112 and the innercatheter 2110 to the most proximal position in the atrial chamber. Usingthe transducer 2116 in a diagnostic mode, rotate the outer catheter 2112(either manually or using the motor drive of console 2132) in thechamber. The generator/receiver will sense for the position of theatrial wall tissue and indicate appropriately with a green or a redlight.

7. If the red light indication exists in a portion of the rotation, usethe linear or bending motions of the catheters 2112 and/or 2110 toachieve a complete green circle. At this point, a contiguous beam path2176 has been established. In the diagnostic mode, the navigationthrough a circle is quite rapid and can be completed in several seconds.Since the circular movement can not continue in one direction only,reverse the direction of rotation after a rotation of 360 degrees plusan overlap of about 10 to 15 degrees. If the physician chooses for themotor drive to achieve this function, the drive unit is programmed toautomatically reverse the direction after a complete circle plus anoverlap.

8. Energize the transducer in the ablation mode and start the rotarymotion of the catheter tip housing 2114 using the motor drive in theconsole 2132. This movement is much slower, and will typically takeseveral minutes to complete. Confirm that the green light stays greenthrough the entire movement.

9. If the red light persists over a portion of the circle, proceed withthe ablation in the green zone, and later cover the red zone ablation inthe following manner: [0205] a. The physician can use the other linearand bending movements of the catheters to establish a path in a set ofother planes which would yield a green path covering the region wherethe original red arc appeared. [0206] b. The computer in thegenerator/receiver can memorize this complex green path, and uponactivation, can establish an ablation zone in the tissue which iscontiguous with the original green zone.

10. The ablation around the two left pulmonary veins LPV1 and LPV2 isnow complete as shown as curve 306 in FIG. 34.

11. Next, the ablation lines 3310 and 312 of FIG. 33 are created using amethod as shown in FIGS. 35A, 35B, 35C, and FIG. 36.

12. Starting at the position of the tip housing 2114 of the catheter2110 at the end point of the just completed ablation ring 306 (FIG. 34),orient the tip 2114 posteriorly in the atrium using the orientationmarkers 2166 and 2168 (ref. FIG. 18) on the proximal ends of thecatheters 2110 and 2112.

13. Advance the catheter 2112 distally towards the LPV1 a fewmillimeters to establish the starting point 324 of the ablation line3310.

14. Using the diagnostic mode, move the catheter 2112 towards the rightpulmonary veins in a manner 314 by pulling it into the guide sheath2118. At the same time, bend the tip of the catheter 2112 in a manner316. If necessary, move the therapy catheter 2110 inside the outercatheter 2112 in a manner 318, and bend the tip of the therapy catheter2110 in a manner 320. All these movements are carried out to establishthe locus of the ablation window 2172 in the green' region. Generally,this locus will be achieved by a combination of various movements of thecatheters 2110 and 2112 and can be carried out by the computer in thegenerator/receiver. The finishing point 326 of this ‘green’ line isintended to be past the ostium of one of the right pulmonary veins. Oncethis horizontal green line 3310 is established, the computer canmemorize the actual motions required therefor.

15. Follow through with the formation ablation line 3310 (FIG. 33) bymoving the tip 2114 in the ablation mode all the while maintaining the‘green’ light. The successive positions of the ablation window 2172 andthe resulting ablation line is shown in the top view of the atrium inFIGS. 35B and 35C.

16. When the catheter tip is at its most proximal position, an ablationzone around the right pulmonary veins can be created as follows: [0214]a. In diagnostic mode, rotate the catheter 2112 in a manner 2124 toestablish a ‘green’ curve around the right pulmonary veins. Otheravailable motions of the catheter set 100 can be utilized to establish a‘green’ curve. [0215] b. Once the ‘green’ curve is established, usingthe ablation mode, create the ablation zone 308.

17. Now referring to FIG. 36, move the tip 2114 of the catheter 2110 toan approximately middle position of the ablation line 3310, and a fewmillimeters clockwise (i.e. above the line 3310) to establish thestarting position 328 for the vertical ablation line 312, as shown inFIG. 33.

18. Using the catheter in the diagnostic mode, rotate the catheter 2112counterclockwise in the manner 2124, and ensure a ‘green’ path isestablished. The end point 330 of this line 312 is at the mitral valveannulus which can be detected by the transducer by virtue of themovements of the leaflet of the valve itself. If required, additionalmovements of the catheters can be used as appropriate to determine thelocus of the ‘green’ line. Once this ‘green’ line is established, enablethe computer to memorize the required movements.

19. Using the transducer in the ablation mode, form an ablation line 312from the horizontal line 2110 down to the annulus of the mitral valve(MV).

20. Withdraw the positioning wires into the lumen of the catheter 2112and withdraw the catheter set 100 from the body of the patient throughthe guide sheath 2118 while leaving the said guide sheath 2118 inposition across the septum.

21. The ablation zone encircling the right pulmonary veins is made usinga different catheter set specifically designed for that anatomy of theregion of the atrium.

22. Referring to FIG. 37, advance the outer catheter 412 distally untilits curved surface 498 is in contact with the inside left wall of theatrium.

23. Place the positioning wires 428 and 430 in the lumen 426 (not shown)of the catheter using the technique described earlier.

24. Position the wires 428 and 430 into the right pulmonary veins usingthe technique described earlier.

25. Advance the therapy catheter 2410 to its most distal position. Usingthe diagnostic mode, rotate the tip housing 414 of the catheter 2410 inthe manner 456. Look for the presence of the ‘green’ circle.

26. If the ‘green’ circle is not established, move the catheter 2410 afew millimeters proximal in the manner 2452 and repeat step 25. Repeatthis step 26 until a ‘green’ circle is established.

27. Now energize the transducer in ablation mode, and create the lesion308 (FIG. 33).

28. If the ‘red’ light appears, follow the procedure in step 9 above.

29. The formation of the right PV ablation zone 308 is now complete.

30. Retract the positioning wires 428 and 430 from the atrium bywithdrawing them through the lumen of the catheter 412.

31. Remove the catheter set 400 from the atrium through the guide sheath2118.

32. Remove the guide sheath 2118 from the heart and follow theconventional closure technique for the femoral vein.

The procedure above describes the formation of one lesion set. As thecatheter sets 100 and 400 are provided with multiple degrees of motions,the physician can create a variety of other lesion sets to achieve aconduction block. FIG. 38 shows some of the lesion sets which can becreated with the device of the present invention. The possible lesionsets are not limited to those presented here, and it is important torecognize that the device of this invention allows the physician tocreate any other lesion set in the atrium of the heart.

In a conventional catheter-based ablation procedures, the physiciancheck the presence or absence of the conduction block by mapping of theatrial tissue. The technique involves checking the electrical conductionbetween the pulmonary veins and the other parts of the atrial wall onthe endocardial side. The wires 428 and 430 are already positionedinside the pulmonary veins and can be easily used as electrodes for thesensing and mapping purposes. The electrical connections to thepositioning wires 428 and 430 are provided at the console 2132.

This specification for the present invention discusses an ultrasoundtransducer as a single element in the shape of a disc mounted at the endof a cylindrical catheter. This invention is not intended to be limitedto the use of a single element circular disc. A rectangular or ovalshaped transducer can be mounted on the cylindrical side of the cathetertip. Appropriate fluid flow mechanism can be provided to cool the saidtransducer and to provide for the separation of the surrounding bloodfrom the surface of the transducer. In addition, the transducerconfiguration is not intended to be limited to that of a disc. Thetransducer can be in the form of an array of multiple transducers. Thetransducer can also be fabricated as a set of concentric circles (knownin the art as an annular array), for example, instead of the singleelement disc described in this invention. One skilled in the art willappreciate the wide possibility of possible shapes, sizes, andconfigurations which can be used for the transducer in this invention.

This specification of the present invention discusses the use of aconsole 2132 that allows simple control of the catheter sets 100 and400. This invention is not intended to be limited to the use of thisconsole. The catheter sets, with appropriate modifications, can also becontrolled and manipulated by other means, for example mechanicalrobotic or magnetic controllers with remote user interfaces that manageall motions, with or without haptic feedback.

In some embodiments, the tip of the treatment catheter and the anchorcan both be made of metal and can communicate electrically with thecontrol system so that they can serve as mapping electrodes fordetermining the electrical characteristics of the heart tissue.

The description above of the device of this invention has been limitedto the treatment of atrial fibrillation in the left atrium of the heart.However, the device, with appropriate modifications, can be used inother parts of the body. For example, if it is determined that the rightatrium is also involved in the condition of atrial fibrillation,appropriate lesion set can be created in the wall of the right atrium aswell. Another example is the use of another version of the device in theventricular space for the treatment of ventricular arrhythmia. Thetransducer creates an ultrasound beam which is capable of creatingtransmural lesions in the myocardial tissue, and this beam can be movedaround in the chambers of the heart to create intended lesions in thewall of the heart.

While preferred embodiments of the present invention have been shown anddescribed herein, it will be obvious to those skilled in the art thatsuch embodiments are provided by way of example only. Numerousvariations, changes, and substitutions will now occur to those skilledin the art without departing from the invention. It should be understoodthat various alternatives to the embodiments of the invention describedherein may be employed in practicing the invention.

What is claimed is:
 1. A method for ablating cardiac tissue, said methodcomprising: advancing a treatment catheter through a patient'svasculature into an atrium of a heart, the treatment catheter comprisingan ultrasound emitter disposed near a distal end thereof; positioningthe ultrasound emitter to face heart tissue within the left atrium andoutside of a pulmonary vein; ablating the heart tissue with ultrasoundenergy from the ultrasound emitter to form a first lesion outside of apulmonary vein while rotating the ultrasound emitter about a firstrotation axis, wherein the first lesion encircles the ostia of thepulmonary vein, wherein the first lesion is formed without directcontact between the ultrasound emitter and the heart tissue, and whereinthe ablating step is performed with the ultrasound energy being directeddistally from a distally facing surface of the ultrasound emitter, andwherein the ultrasound energy is initially directed at an inner wall ofthe heart; sensing a gap distance with a sensor coupled to the treatmentcatheter, the gap distance extending between the ultrasound emitter andthe heart tissue; based on the sensed gap distance, controllingre-positioning of the ultrasound emitter position by adjusting the gapdistance between the ultrasound emitter and the heart tissue whilemaintaining the gap therebetween within an ablation window length,wherein adjusting comprises proximal or distal axial movement of theultrasound emitter relative to the heart tissue; cooling the ultrasoundemitter with fluid wherein the fluid flows past the ultrasound emitterand exits the treatment catheter; and providing a separation between theultrasound emitter and blood in the atrium to prevent the blood fromcoagulating on the ultrasound emitter, wherein the separation comprisesthe fluid.
 2. The method of claim 1, wherein the ultrasound energy fromthe ultrasound emitter comprises a collimated beam.
 3. The method ofclaim 1, wherein the ultrasound emitter comprises an ultrasoundtransducer, and wherein the sensor comprises the ultrasound transducer.4. The method of claim 1, wherein the positioning comprises bending adistal portion of the treatment catheter.
 5. The method of claim 1,further comprising anchoring the treatment catheter.
 6. The method ofclaim 5, wherein anchoring the treatment catheter comprises placing ananchor against a wall of the atrium.
 7. The method of claim 5, whereinanchoring the treatment catheter comprises placing an anchor within apulmonary vein.
 8. The method of claim 5, wherein anchoring thetreatment catheter comprises expanding an anchor.
 9. The method of claim1, wherein positioning comprises rotating the treatment catheter. 10.The method of claim 1, further comprising sensing depth of ablation inthe heart tissue and adjusting the ultrasound energy.
 11. The method ofclaim 10, wherein the ultrasound emitter comprises an ultrasoundtransducer and sensing the depth of ablation comprises sensing the depthof ablation with the ultrasound transducer.
 12. The method of claim 1,further comprising: ablating the heart tissue with ultrasound energyfrom the ultrasound emitter to form a second lesion outside of a secondpulmonary vein while rotating the ultrasound emitter about a secondrotation axis, wherein the second lesion encircles the ostia of thesecond pulmonary vein, wherein the second lesion is formed withoutdirect contact between the ultrasound emitter and the heart tissue, andwherein ablating the second pulmonary vein is performed with theultrasound energy being directed distally from a distally facing surfaceof the ultrasound emitter, and wherein the ultrasound energy isinitially directed at an inner wall of the heart.
 13. The method ofclaim 12, further comprising ablating the heart tissue with theultrasound energy to form a connecting lesion while moving theultrasound emitter between the first lesion and the second lesion,wherein the connecting lesion crosses the first and the second lesions.14. The method of claim 13, further comprising ablating the heart tissuewith the ultrasound energy to form a transverse lesion while moving theultrasound emitter between the connecting lesion and the mitral valve,wherein the transverse lesion crosses the connecting lesion and extendstoward the mitral valve.
 15. The method of claim 1, further comprisingcontrolling lesion depth by adjusting distance between the ultrasoundemitter and the heart tissue with proximal or distal axial movement ofthe ultrasound emitter relative to the heart tissue.
 16. The method ofclaim 1, further comprising controlling lesion depth by adjusting theultrasound energy.
 17. The method of claim 1, further comprising sensingheart tissue thickness and controlling depth of the first lesion byadjusting distance between the ultrasound emitter and the heart tissuewith proximal or distal axial movement of the ultrasound emitterrelative to the heart tissue.
 18. The method of claim 1, furthercomprising sensing thickness of the heart tissue and controlling depthof the first lesion by adjusting the ultrasound energy.